Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
65% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 84
Deficiencies: 15
Date: Aug 27, 2024
Visit Reason
Routine state inspection of Ignite Medical Resort St Marys LLC to assess compliance with healthcare regulations including resident care, safety, medication management, and facility conditions.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity and privacy during care, incomplete medication self-administration orders and evaluations, environmental cleanliness issues, inadequate skin and wound care, incomplete physician visits, improper catheter care, oxygen equipment storage issues, food temperature and preparation problems, visitor food labeling issues, call system audibility problems, and unsafe facility maintenance.
Deficiencies (15)
F 0550: The facility failed to provide dignity and privacy during Activities of Daily Living and perineal care for one resident, exposing the resident to bystanders due to open window curtains.
F 0554: The facility failed to obtain physician orders and evaluate ability for self-administration of medication for two residents, and lacked policy for resident self-administration at time of exit.
F 0584: The facility failed to maintain cleanable commode risers, clean fans and vents, repair damaged countertops and grab bars, and replace broken shower chairs, affecting multiple resident rooms.
F 0684: The facility failed to timely act on identified skin issues, obtain treatment orders, complete weekly skin assessments, and follow up on skin changes for two residents at risk for pressure ulcers.
F 0690: The facility failed to ensure timely physician visits for six residents, including one resident not seen by a physician for 10 months.
F 0695: The facility failed to ensure proper catheter care including cleaning of insertion site and failed to implement hospital discharge orders for a voiding trial for one resident.
F 0745: The facility failed to provide trauma informed care or develop a care plan addressing PTSD for one resident diagnosed with PTSD.
F 0756: The facility failed to ensure timely physician documentation of rationale for disagreement with pharmacist medication recommendations for two residents and failed to follow up on gradual dose reduction recommendations for psychotropic medications.
F 0804: The facility failed to maintain hot food temperatures at or near 120°F and cold milk temperatures at or near 41°F on room trays during delivery on C and E Halls.
F 0805: The facility failed to ensure pureed sausage was prepared to a smooth consistency without graininess.
F 0812: The facility failed to maintain kitchen floors, utensil racks, sprinkler heads, and entryway clean and free from dust and food debris, and failed to maintain milk temperature in the dining room.
F 0813: The facility failed to ensure visitor food stored in the visitor's refrigerator was properly labeled with resident name and date, and contained unlabeled or undated items.
F 0814: The facility failed to maintain the outdoor dumpster lid in good repair and prevent trash accumulation around the dumpster.
F 0919: The facility failed to ensure the audible portion of the call system was operational at the nurse's area on C Hall, affecting 14 residents.
F 0921: The facility failed to maintain cleanout covers in a tight fitting manner on C Hall and between D Hall and Rehabilitation Unit nurse's station, creating a hazard.
Report Facts
Resident census: 84
Deficiency count: 15
Temperature: 63.9
Temperature: 108.1
Temperature: 102.2
Temperature: 53.2
Wound measurement: 5.3
Wound measurement: 4
Wound measurement: 0.5
Wound measurement: 2.5
Wound measurement: 4
Wound measurement: 0.9
Wound measurement: 3
Wound measurement: 2.6
Wound measurement: 2.1
Wound measurement: 7
Wound measurement: 0.2
Inspection Report
Census: 84
Deficiencies: 7
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on environmental cleanliness and equipment maintenance.
Findings
The facility failed to maintain commode risers in multiple resident rooms free from areas that were not easily cleanable, failed to maintain fans and ceiling vents free from dust buildup, failed to keep floors clean in certain rooms, failed to repair damaged countertops and grab bars, and failed to ensure shower chairs were in good repair. These deficiencies potentially affected at least 30 residents.
Deficiencies (7)
Failed to maintain commode risers in multiple resident rooms free from areas that were not easily cleanable
Failed to maintain the fan in resident room B105 free from a buildup of dust
Failed to maintain the ceiling vent in resident room A101 free from heavy dust buildup
Failed to ensure the floor was maintained clean in resident rooms A105 and C109
Failed to ensure the countertop in the A Hall shower room was in good repair (missing tile pieces)
Failed to ensure the grab bar was firmly attached to the wall in the restroom of B105
Failed to ensure the shower chair in D105 was in good repair (broken and needed to be discarded)
Report Facts
Residents affected: 30
Facility census: 84
Missing tile pieces length: 12
Missing tile pieces length: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper B | Housekeeper | Reported on fan cleaning and loose grab bar |
| Environmental Services Director | Interviewed multiple times regarding deficiencies and maintenance issues |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 7
Date: Oct 25, 2022
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to properly manage resident funds, ensure background checks for employees, follow feeding tube orders, limit psychotropic medication use, maintain proper sanitation, and ensure working call light systems for residents.
Complaint Details
The complaint investigation was triggered by allegations of improper management of resident funds, failure to conduct proper employee background checks, failure to follow medical orders for feeding tubes, inappropriate use of psychotropic medications, sanitation issues with dumpsters, and lack of accessible call light systems for residents.
Findings
The facility was found deficient in multiple areas including failure to obtain resident signatures for goods and services, improper handling and commingling of resident funds, incomplete employee background checks, failure to follow physician orders for tube feeding, lack of timely re-evaluation of psychotropic PRN medications, failure to keep dumpster lids closed, and failure to maintain a working call light system accessible to a resident.
Deficiencies (7)
Failed to ensure resident signatures were obtained for goods and services and proper handling of resident funds.
Failed to properly hold, secure, and manage each resident's personal money and prevent commingling of funds.
Failed to check Employee Disqualification List as part of background checks for newly hired employees and failed to check current employees against quarterly updates.
Failed to follow physician's orders for continuous tube feeding for one resident.
Failed to limit PRN anti-anxiety medication use to 14 days and ensure physician re-evaluation.
Failed to ensure dumpster lids were closed for three days during the survey.
Failed to ensure a working call light system or alternate system was consistently accessible within reach for one resident dependent on staff for ADLs.
Report Facts
Facility census: 76
Resident funds amount: 3789.77
Resident funds amount: 646.82
Resident funds amount: 2221.06
Resident funds amount: 3040.3
Resident funds amount: 15550.64
Number of employees: 151
PRN Ativan doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Newly hired employee | Failed to have complete background check including EDL quarterly updates |
| Employee F | Newly hired employee | Failed to have complete background check including EDL quarterly updates |
| Business Office Manager | Responsible for resident trust funds accounts and signed receipts as representative payee | |
| Director of Culture and Engagement | Responsible for prospective new employee background screenings | |
| Assistant Chief Nursing Officer A | Provided clarifications on tube feeding and call light system issues | |
| Chief Nursing Officer | Provided clarifications on tube feeding and call light system issues | |
| Licensed Practical Nurse A | Provided information on PRN medication re-certification | |
| Nursing Assistant A | Reported call button pendant not working and checked on resident | |
| Certified Nursing Assistant A | Reported call button pendant not working and checked on resident |
Inspection Report
Routine
Census: 75
Deficiencies: 9
Date: Jan 14, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations including dignity in care, financial management, cleanliness, discharge procedures, medication administration, personal care, respiratory care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to assist residents with dignity during meals, improper distribution of resident trust fund interest, inadequate cleanliness of bathrooms and handrails, failure to provide timely written discharge notifications, incomplete discharge summaries, improper medication administration techniques, incomplete perineal care, failure to date and clean oxygen equipment, and lapses in infection control practices including hand hygiene and catheter care.
Deficiencies (9)
Failed to treat residents with dignity and respect during meal times by not assisting a resident with feeding needs.
Failed to distribute interest evenly to residents in the Resident Trust Fund.
Failed to maintain a clean environment including bathrooms and handrails; laundry service was not timely.
Failed to provide written notice of transfer or discharge to residents and responsible persons.
Failed to complete comprehensive discharge summaries for discharged residents.
Failed to follow manufacturer guidelines for administering nasal spray and eye drops and wound treatment orders.
Failed to provide complete perineal care for residents dependent on staff assistance.
Failed to date oxygen tubing and maintain oxygen concentrator filters clean and free of dust.
Failed to follow infection control protocols during medication administration and catheter drainage bag emptying.
Report Facts
Residents affected: 19
Resident Trust Fund accounts: 17
Resident census: 75
Interest earned: 1.24
Interest earned: 0.94
Interest earned: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration and wound care deficiencies |
| LPN C | Licensed Practical Nurse | Named in medication administration deficiencies |
| CNA A | Certified Nurse Aide | Named in dignity and perineal care deficiencies |
| CNA G | Certified Nurse Aide | Named in catheter care and perineal care deficiencies |
| Director of Nurses | Director of Nursing | Provided interview statements regarding care expectations and deficiencies |
| Business Office Manager | Provided interview statements regarding Resident Trust Fund interest distribution | |
| Lead Housekeeper | Provided interview statements regarding housekeeping and laundry services | |
| Executive Director | Provided interview statements regarding facility issues and corrective actions | |
| RN A | Registered Nurse | Named in discharge notification deficiencies |
| CNA E | Certified Nurse Aide | Named in perineal care deficiencies |
| Social Worker A | Provided interview statements regarding discharge summary follow-up |
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