Inspection Reports for
Life Care Center of St Louis
3520 CHOUTEAU AVE, SAINT LOUIS, MO, 63103-2916
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
18.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
238% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
90% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 90
Deficiencies: 2
Date: Jan 16, 2026
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, including review of resident care, physician orders, and assistance with activities of daily living.
Findings
The facility failed to ensure timely transcription of a physician order for a resident's nephrostomy tube care and failed to provide adequate assistance with showers and personal care, including hair washing, for another resident. Both deficiencies were determined to cause minimal harm and affected a few residents.
Deficiencies (2)
Failure to ensure services met professional standards when a resident's physician order for nephrostomy tube care was not transcribed timely.
Failure to provide showers and personal care, including hair washing, in accordance with resident needs for a resident requiring assistance with activities of daily living.
Report Facts
Sample size: 23
Census: 90
Physician order documentation opportunities: 25
Physician order documentation completed: 19
Showers provided: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse E | LPN | Described nurse responsibilities for entering and confirming physician orders |
| Nurse Manager | Described admissions process and order verification | |
| Registered Nurse N | RN | Discussed expectations for reading discharge orders and nephrostomy tube care |
| Nurse Practitioner | NP | Verified orders and general instructions for nephrostomy tube care |
| Registered Nurse Q | RN | Explained nephrostomy tube purpose and care |
| Certified Nursing Assistant O | CNA | Provided information about resident's need for assistance with showers and personal care |
| Certified Nursing Assistant I | CNA | Reported on shower schedule and hair care practices |
| Registered Nurse P | RN | Confirmed resident's need for assistance with showers and personal care |
| Regional Nurse, Regional [NAME] President and Operations Specialist | Stated resident should have received at least two showers per week including hair washing | |
| Director of Nursing | Confirmed resident's orders were verified with physician on admission |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician orders for x-rays for a resident who fell from his/her bed on 09/06/2024.
Complaint Details
The complaint investigation found that the facility did not complete ordered x-rays for Resident #1 for nine days after a fall on 09/06/2024, causing the resident to experience pain and refuse care. The Immediate Jeopardy was identified on 10/21/2024 and corrected on 09/16/2024.
Findings
The facility failed to complete stat x-rays ordered on 09/06/2024 for Resident #1 until 09/13/2024, resulting in delayed diagnosis of a fractured hip. The resident experienced pain and refused care during this period. Staff were inserviced and a monitoring system was implemented to ensure completion of ordered x-rays. Immediate Jeopardy was identified and corrected by 09/16/2024.
Deficiencies (1)
Failure to complete stat x-rays ordered on 09/06/2024 for a resident who fell, resulting in delayed diagnosis of fractured hip and prolonged pain.
Report Facts
Residents affected: 7
Census: 86
Pain medication dosage: 50
Tylenol dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Reported resident's pain and care difficulties after fall |
| Assistant Director of Nurses | ADON | Assessed resident after fall, obtained x-ray orders, but failed to ensure x-rays were completed |
| LPN D | Licensed Practical Nurse | Worked on 09/13/24 shift, aware of x-ray order but did not receive results |
| LPN E | Licensed Practical Nurse | Provided care post-fall, administered pain medication, did not receive x-ray results |
| LPN G | Licensed Practical Nurse | Assisted resident off floor after fall, did not follow up on x-ray completion |
| LPN F | Licensed Practical Nurse | Recalled hearing about x-ray order but did not follow up |
| CNA B | Certified Nurse Aide | Reported resident's pain and refusal to get out of bed after fall |
| CNA C | Certified Nurse Aide | Reported resident's pain complaints and care difficulties |
| Director of Nursing | DON | Unaware x-rays were not completed until 09/13/24, expected staff to complete orders |
| Medical Director | Physician | Expected staff to complete x-rays as ordered and notify if mobile imaging unable to complete |
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 1
Date: Oct 21, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of St Louis following a survey completed on 10/21/2024. It addresses deficiencies related to quality of care, specifically failure to follow physician orders for x-rays for a resident who experienced a fall and pain.
Findings
The facility failed to complete ordered x-rays for one of seven sampled residents who fell and experienced pain, resulting in delayed diagnosis of a fractured hip. Multiple interviews and record reviews showed incomplete x-ray documentation and delayed follow-up on physician orders.
Deficiencies (1)
F684 Quality of care: The facility failed to follow physician orders for x-rays for one resident who fell and experienced pain, resulting in delayed diagnosis of a fractured hip. Documentation showed incomplete x-rays and delayed follow-up on orders.
Report Facts
Census: 86
Sample size: 7
Inspection Report
Census: 92
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with discharge planning requirements, specifically regarding timely referrals to local contact agencies and orders for medical equipment for residents being discharged to the community.
Findings
The facility failed to ensure a safe resident discharge for one of two residents reviewed by not sending timely referrals to home health and durable medical equipment providers after a change in the discharge date. This failure had the potential to affect all residents discharged from the facility.
Deficiencies (1)
Failed to ensure referrals to local contact agencies and orders for medical equipment were sent timely for a resident discharged home, resulting in discharge without home health set up or durable medical equipment after a change in discharge date.
Report Facts
Census: 92
Residents Affected: 2
Residents Affected: Few
Inspection Report
Routine
Census: 92
Deficiencies: 12
Date: Apr 23, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, assessments, medication administration, discharge planning, staffing, and infection control.
Findings
The facility had multiple deficiencies including failure to submit timely transfer notifications to the Ombudsman, incomplete and delayed resident assessments, incomplete care plans, failure to ensure safe discharge planning and follow-up, lack of communication aids for a deaf resident, medication administration errors including holding insulin without physician orders, improper medication and treatment cart storage, failure to post nurse staffing daily, inadequate staff training, and infection control lapses including improper glove use and uncovered suction equipment.
Deficiencies (12)
Failed to submit facility initiated transfer notifications to the Ombudsman on a monthly basis.
Failed to complete comprehensive resident assessments timely for admission and quarterly MDS assessments.
Failed to encode and transmit resident assessment data within 7 days after completion.
Failed to develop and implement complete care plans addressing all resident needs including wound care, mental health, dietary, and discharge planning.
Failed to ensure safe discharge planning including timely referrals to home health and durable medical equipment providers.
Failed to provide communication aids and ensure staff knowledge for a deaf resident.
Failed to provide required annual 12 hour in-service training for eight of ten randomly selected CNAs.
Failed to post nurse staffing information daily in a prominent and accessible location.
Failed to administer insulin as ordered; held routine insulin without physician notification or order.
Failed to label insulin pens with date removed from refrigeration and expiration date; ointments stored uncovered on treatment cart.
Failed to follow infection control practices including failure to change gloves between medication preparation and administration and leaving suction equipment uncovered.
Failed to complete two-step tuberculosis testing for eight of eight new hire employees as per policy.
Report Facts
Census: 92
Deficiencies cited: 12
CNA in-service hours: 0
CNA in-service hours: 7.49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Responsible for setting up resident's physician appointments and transportation |
| Nurse U | Nurse | Responsible for checking transportation log daily |
| Administrator | Provided information on care plan expectations, staffing, and transportation processes | |
| MDS Coordinator | Responsible for resident assessments and care plan updates | |
| Wound Nurse | Responsible for wound care and treatment cart maintenance | |
| Assistant Director of Nursing | ADON | Provided information on medication administration, infection control, and TB testing policies |
| Certified Nursing Assistant G | CNA | Mentioned regarding communication with deaf resident |
| Certified Nursing Assistant H | CNA | Mentioned regarding communication with deaf resident and suction equipment use |
| Registered Nurse J | RN | Provided information on hand hygiene and suction equipment use |
| Licensed Practical Nurse C | LPN | Observed holding insulin without physician notification |
| Licensed Practical Nurse T | LPN | Observed medication administration without glove changes or hand hygiene |
Inspection Report
Routine
Census: 87
Deficiencies: 3
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards regarding treatment and care of residents, specifically focusing on wound care and pressure ulcer prevention and management.
Findings
The facility failed to ensure that residents received care consistent with physician orders and professional standards. Two residents did not have treatments completed as ordered for vascular wounds and pressure ulcers, and weekly skin assessments were not consistently performed due to a system glitch. Documentation of treatments was incomplete, and some wounds were not properly assessed or treated.
Deficiencies (3)
Resident #4 did not have treatments completed as per physician orders for vascular wounds on bilateral lower extremities.
Resident #3 did not have treatment on breasts and no follow-up skin assessments were completed to ensure wound healing.
Residents #5 and #1 with pressure wounds did not receive necessary treatments and services to promote healing, and treatments were not documented as completed.
Report Facts
Census: 87
Sample size: 5
Number of venous and arterial ulcers: 2
Braden score date: Jan 20, 2024
Wound size length: 0.5
Wound size width: 0.5
Wound size depth: 0.1
Pressure ulcer stage 2 wound length: 1
Pressure ulcer stage 2 wound width: 2.5
Pressure ulcer stage 2 wound depth: 0.1
Posterior heel wound length: 0.4
Posterior heel wound width: 2
Lateral heel wound length: 0.5
Lateral heel wound width: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding wound care treatments and documentation; verified orders and treatment expectations. |
| LPN C | Licensed Practical Nurse | Interviewed about weekly skin assessments and treatment responsibilities. |
| LPN D | Licensed Practical Nurse | Observed removing dressings and discussed treatment frequency for Resident #4. |
| LPN E | Licensed Practical Nurse | Assisted resident with turning and observed wound condition. |
| CNA B | Certified Nursing Assistant | Interviewed about resident assistance and skin issue reporting. |
| CNA F | Certified Nursing Assistant | Assisted resident with turning during observation. |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies, treatment documentation, and system issues affecting skin assessments. |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed skin assessments and dressing changes during inspection. |
Inspection Report
Plan of Correction
Census: 87
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding quality of care and pressure ulcer prevention and treatment at Life Care Center of St Louis.
Findings
The facility failed to ensure residents received care consistent with professional standards, specifically in wound care and pressure ulcer prevention. Deficiencies included incomplete treatments, lack of documentation, and failure to perform required skin assessments.
Deficiencies (2)
F684 Quality of care: The facility failed to ensure residents received treatment and care consistent with professional standards, including incomplete wound treatments and lack of follow-up skin assessments for residents with vascular wounds and leg ulcers.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to provide necessary treatments and services to two residents with pressure wounds, including incomplete wound care and missing documentation of treatments.
Report Facts
Census: 87
Sample size: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
The inspection was a COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey conducted on 01/19/2023 as a complaint investigation.
Complaint Details
The complaint investigation focused on COVID-19 infection control and emergency preparedness. No deficiencies were found or cited.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 13
Date: Mar 30, 2022
Visit Reason
The inspection was conducted based on complaints alleging failure to protect residents' rights, failure to notify residents of financial account limits, failure to provide timely transfer and bed hold notices, medication administration errors, inadequate activities programming, failure to maintain medical records, infection control issues, and staff vaccination compliance.
Complaint Details
Complaint investigation related to residents' rights violations, financial notification failures, transfer and discharge notification failures, medication administration errors, inadequate activities programming, incomplete medical records, infection control deficiencies, and staff vaccination compliance.
Findings
The facility was found deficient in multiple areas including failure to protect residents' dignity and privacy, failure to notify residents or representatives about Medicaid account limits and transfer/bed hold policies, medication errors including failure to notify physicians of abnormal blood glucose levels and improper insulin administration, inadequate activities programming and documentation, failure to maintain complete medical records, improper storage and labeling of medications, failure to ensure staff tuberculosis testing compliance, and failure to ensure full COVID-19 vaccination and mask use among staff.
Deficiencies (13)
Failure to protect residents' rights to dignity and privacy, including harsh treatment of Resident #8 and lack of privacy during care for Residents #38, #25, and #23.
Failure to notify residents or responsible parties when resident trust accounts exceeded Medicaid limits for 10 residents.
Failure to provide timely written notification of transfer to hospital for Residents #252, #36, and #45.
Failure to provide written bed hold policy notification at time of hospital transfer for Residents #252, #36, and #45.
Failure to follow physician orders and facility standing orders for blood glucose monitoring and notification for Residents #26, #10, and #301; failure to ensure correct arm used for blood pressure for Resident #21; failure to ensure oxygen and CPAP orders for Resident #7; failure to discontinue droplet precautions for Resident #43.
Failure to provide ongoing, meaningful, and individualized activities programming including evenings and weekends; failure to document 1:1 activities for Residents #13, #32, #23, and #17.
Failure to ensure Resident #17 wore ordered splints to prevent loss of range of motion; failure to document refusals and address issues with splint use.
Medication error rate of 11.53% observed with 3 errors in 26 opportunities including missed medication doses, incorrect medication form administered, and improper insulin administration technique.
Failure to ensure Resident #251 received blood pressure medication timely resulting in elevated blood pressure.
Failure to label and store medications properly including undated opened insulin pens, unlabeled topical medications, and unlocked treatment carts.
Failure to maintain complete medical records for Resident #301 resulting in delay of complaint investigation.
Failure to ensure newly hired staff received two-step tuberculosis skin testing as required for 8 of 10 sampled staff.
Failure to ensure 100% staff COVID-19 vaccination by March 15, 2022 deadline; failure to require unvaccinated staff to wear N95 masks as per facility policy.
Report Facts
Medication error rate: 11.53
Staff vaccination rate: 96.9
Staff not fully vaccinated: 2
Residents affected by Medicaid notification failure: 10
Residents affected by transfer notification failure: 3
Residents affected by bed hold notification failure: 3
Residents affected by medication errors: 3
Residents affected by activities deficiencies: 3
Residents affected by splint use deficiency: 1
Staff without two-step TST: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN R | Registered Nurse | Named in medication error and missing medication finding for Resident #251 |
| DON | Director of Nursing | Interviewed regarding multiple findings including residents' rights, medication administration, activities, and infection control |
| Administrator | Interviewed regarding multiple findings including residents' rights, medication administration, activities, and infection control | |
| Activity Director | Named in activities programming deficiencies | |
| Director of Rehab | Named in splint use deficiency for Resident #17 | |
| Medical Director | Interviewed regarding medication administration and staff vaccination | |
| CMT Q | Certified Medication Technician | Named in medication cart and insulin storage deficiencies |
| RN P | Registered Nurse | Named in medication administration and treatment cart deficiencies |
| Staff Person V | Named in COVID-19 vaccination deficiency and mask use observation | |
| Staff Person W | Named in COVID-19 vaccination deficiency and mask use observation | |
| CNA T | Certified Nursing Assistant | Named in splint use deficiency |
| CNA U | Certified Nursing Assistant | Named in splint use deficiency |
| Wound Nurse | Named in medication labeling and storage deficiencies |
Inspection Report
Life Safety
Census: 55
Capacity: 100
Deficiencies: 7
Date: Mar 30, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including unauthorized access to fire alarm panels, deficiencies in sprinkler system maintenance, inadequate smoke barrier walls, malfunctioning smoke doors, elevator safety violations, electrical system deficiencies, and improper oxygen cylinder storage.
Deficiencies (7)
K345 Fire Alarm System - The facility failed to ensure only authorized personnel could access, silence, and reset the main fire alarm panel and annunciator panels, posing a risk to all occupants.
K353 Sprinkler System - The facility failed to maintain the sprinkler system according to NFPA 25 standards and did not provide required signage for fire department connection valves.
K372 Smoke Barrier Construction - The facility failed to maintain smoke barrier walls with the required 1/2-hour fire resistance rating, affecting residents in two smoke compartments.
K374 Smoke Barrier Doors - The facility failed to ensure smoke doors closed properly during fire alarm tests, affecting residents in four smoke compartments.
K531 Elevators - The facility failed to obtain current state operating certificates for two elevators and maintain elevator pits free of debris, risking occupant safety.
K918 Electrical Systems - The facility failed to maintain the emergency generator with required fuel supply and testing, risking power loss during emergencies.
K923 Gas Equipment - The facility failed to maintain proper storage and separation of oxygen cylinders, risking occupant safety.
Report Facts
Facility capacity: 100
Resident census: 55
Deficiency counts: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 12/28/2020 through 12/29/2020 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from 11/18/2020 through 11/20/2020 to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness. No deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Date: Sep 18, 2020
Visit Reason
The inspection was a COVID-19 focused emergency preparedness survey conducted from 09/16/2020 through 09/18/2020, triggered by allegations of abuse, neglect, exploitation, or mistreatment related to a resident elopement incident.
Complaint Details
The complaint investigation was substantiated. The facility failed to report a resident elopement incident timely and failed to provide adequate supervision and training to prevent elopement, resulting in the resident leaving the premises unsupervised.
Findings
The facility failed to report an elopement incident within the required two-hour timeframe and did not provide adequate supervision, training, and interventions to prevent elopement for a resident at risk. The resident left the building and was found off premises, and the facility's policies and staff training related to elopement risk were found deficient.
Deficiencies (3)
F609: The facility failed to report an elopement for one resident within the required two-hour timeframe and failed to provide adequate supervision and training to prevent elopement. The resident eloped from the facility and was found near a busy intersection 0.1 miles away.
A4073: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, including procedures to inquire about residents' whereabouts during voluntary leave.
A8025: The facility failed to immediately report suspected abuse or neglect to the Department of Health and Senior Services as required by regulation.
Report Facts
Resident census: 61
Distance of elopement: 0.1
Deficiency count: 3
Inspection Report
Plan of Correction
Census: 81
Deficiencies: 1
Date: Jan 30, 2020
Visit Reason
The inspection was conducted to address a past noncompliance related to quality of care, specifically regarding a resident's safety during van transportation and a fall incident.
Findings
The facility failed to ensure a resident's seatbelt was fastened securely during van transportation, resulting in a fall when the van driver hit the brakes. The van driver moved the resident back into the wheelchair without proper medical assessment. The van driver was suspended and later terminated. The resident was assessed and had a skin assessment completed.
Deficiencies (1)
F684 Quality of care: The facility failed to ensure a resident's seatbelt was fastened securely during van transportation and did not follow facility policy after a fall in the transport van. The van driver moved the resident back into the wheelchair without proper medical assessment.
Report Facts
Resident census: 81
Sampled residents: 13
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 2
Date: Dec 19, 2019
Visit Reason
The inspection was conducted to assess compliance with quality of care regulations following concerns about the care provided to residents, specifically regarding recognition and assessment of stroke risk factors and timely interventions.
Findings
The facility failed to provide necessary care and services for one of three sampled residents, including failure to recognize and assess stroke risk factors, monitor and evaluate the resident's response to interventions, causing a delay in transfer to the hospital. The resident's condition showed confusion, elevated respirations, and visual deficits, with inadequate nursing documentation and communication.
Deficiencies (2)
F684 Quality of care was not met as the facility failed to provide necessary care and services for a resident, including failure to recognize stroke risk factors and timely interventions, causing a delay in hospital transfer.
A4074 Nursing care per resident condition was deficient as the facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, violating Class II regulations.
Report Facts
Resident census: 73
Deficiency cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eugenie Dixon | Director of Nursing | Named in plan of correction signature and interview regarding nursing staff education |
Inspection Report
Routine
Census: 74
Deficiencies: 12
Date: Nov 20, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate care planning, improper catheter care, unsafe medication self-administration practices, incomplete dialysis documentation and contracts, lack of required CNA training, food safety violations, and lapses in infection control procedures.
Deficiencies (12)
Staff failed to treat residents with dignity and respect, including inappropriate language and failure to provide clean clothing and privacy.
Failure to obtain and ensure accurate physician orders for residents' code status and discrepancies in documentation.
Failure to provide written notice of bed hold policy to residents or their representatives upon hospital transfer.
Incomplete and inaccurate discharge care plans for multiple residents, lacking documentation of discharge goals and interventions.
Failure to provide thorough perineal care to a resident, including incomplete cleansing of genital and buttocks areas.
Failure to supervise a resident requiring assistance while eating and failure to follow self-administration medication policy, including unsecured medications in resident rooms.
Improper catheter care including catheter drainage bags not maintained below bladder level and tubing loops preventing urine flow.
Failure to have physician orders for dialysis, lack of communication and documentation between facility and dialysis center, incomplete pre/post dialysis assessments, and missing dialysis contracts.
Failure to provide required annual 12-hour CNA training for eight randomly selected CNAs.
Failure to store food properly including unlabeled, undated, and expired food items in kitchen storage areas.
Failure to follow infection control procedures including improper isolation precautions for residents with infectious diseases, failure to follow hand hygiene policy, and failure to provide clean utensils during meal service.
Failure to ensure new employees received tuberculosis skin testing per facility policy, lacking documentation of negative PPD or chest x-ray prior to hire for 4 of 7 employees sampled.
Report Facts
Sample size: 18
Census: 74
Weight loss percentage: 18.13
CNA training hours missing: 8
Dialysis residents: 9
Employees missing TB documentation: 4
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 11
Date: Nov 20, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for nursing facilities, including resident rights, care plans, infection control, and other regulatory requirements.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents were treated with dignity, incomplete care plans, inadequate infection control practices, improper medication storage, and failure to provide required staff training. Several residents were at risk due to these deficiencies.
Deficiencies (11)
F550 Resident Rights: The facility failed to ensure staff treated residents with respect and dignity, including inappropriate staff communication and failure to maintain resident privacy.
F578 Advance Directives: The facility failed to obtain physician orders for code status for three sampled residents and did not ensure code status matched physician orders.
F625 Bed Hold Policy: The facility failed to provide written notice of bed hold policy to residents or their legal representatives at the time of transfer for five residents.
F656 Care Plans: The facility failed to ensure residents had complete, accurate, and individualized care plans addressing discharge needs and other care requirements.
F677 Perineal Care: The facility failed to ensure proper perineal care was provided to a resident, resulting in inadequate hygiene and risk of infection.
F689 Environment: The facility failed to maintain a clean, odor-free environment and failed to ensure residents were free from accident hazards, including proper storage of hazardous materials.
F690 Incontinence: The facility failed to provide adequate care and supervision for residents with urinary and bowel incontinence, including catheter care and prevention of infection.
F698 Dialysis: The facility failed to have physician orders for dialysis, complete pre/post dialysis assessments, and proper communication with dialysis centers for nine residents.
F730 Nurse Aide Training: The facility failed to ensure eight certified nurse aides received required annual 12-hour training.
F812 Food Safety: The facility failed to properly store and label food items, including expired and undated foods, posing a risk to resident safety.
F880 Infection Control: The facility failed to implement effective infection prevention and control practices, including hand hygiene, isolation precautions, and tuberculosis testing for staff.
Report Facts
Resident census: 74
Resident sample size: 18
Certified Nurse Aides with missing training: 8
Employees tested for TB: 7
Inspection Report
Life Safety
Census: 74
Capacity: 100
Deficiencies: 9
Date: Nov 20, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with emergency preparedness training and life safety code requirements.
Findings
The facility failed to provide annual emergency preparedness training to all staff and failed to maintain compliance with life safety code requirements including delayed egress door release, fire extinguisher maintenance, smoke door closure, electrical wiring, and oxygen storage. These deficiencies had the potential to affect all residents and staff.
Deficiencies (9)
E037 Emergency preparedness training was not provided annually to all facility staff, with only nursing staff attending the training. This deficiency affected all occupants of the building.
K222 The facility failed to ensure one of three delayed egress exit doors released within 15 seconds when pushed, potentially affecting all residents and staff.
K355 Fire extinguishers were not maintained or inspected monthly, affecting residents in two of 16 smoke compartments and all staff and visitors using the smoking patio.
K374 Smoke barrier doors on the fourth floor did not close properly during fire alarm tests, potentially affecting residents in two of four smoke compartments.
K511 The facility failed to maintain electrical wiring in compliance with the National Electrical Code, with multiple electrical outlet and extension cord issues observed, potentially affecting occupants in five of 16 smoke compartments.
K741 Smoking regulations were not met as ashtrays were improperly maintained and disposed of, and smoking areas contained cigarette butts and trash, affecting all staff and visitors using the smoking area.
K914 Non-hospital grade electrical receptacles in patient sleeping areas were not tested annually, potentially affecting all residents.
K923 The facility failed to maintain oxygen cylinder storage according to NFPA code, with mixed full and empty cylinders stored together, potentially affecting occupants in two of 16 smoke compartments.
K926 Personnel were not trained on maintenance and operation of medical gas systems, potentially affecting all residents using medical gases.
Report Facts
Facility capacity: 100
Resident census: 74
Staff attending emergency preparedness training: 31
Total staff: 119
Inspection Report
Plan of Correction
Census: 83
Deficiencies: 2
Date: Mar 21, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to accident hazards, supervision, and protective oversight at Life Care Center of St Louis, following incidents involving resident falls and injuries.
Findings
The facility failed to ensure a safe environment free of accident hazards and adequate supervision to prevent resident falls. Multiple falls occurred resulting in head injuries requiring hospitalization, and the facility lacked proper interventions and oversight for residents at risk of falls.
Deficiencies (2)
F689: The facility failed to implement interventions to ensure residents received adequate supervision and assistance devices to prevent accidents, resulting in multiple falls with head injuries requiring hospitalization. Resident #1 was assessed as a fall risk but interventions were insufficient to keep the resident safe.
A4073: The facility did not have a procedure to inquire about the resident's whereabouts during voluntary leave, failing to provide twenty-four hour protective oversight and supervision as required.
Report Facts
Resident census: 83
Fall incidents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse P | Witnessed resident falls and provided care during incidents | |
| Director of Nursing | Director of Nursing | Interviewed regarding fall risk evaluation and interventions |
Inspection Report
Life Safety
Census: 78
Capacity: 100
Deficiencies: 17
Date: Jan 11, 2019
Visit Reason
The inspection was conducted as a life safety code survey to assess compliance with fire safety and emergency preparedness regulations at the Life Care Center of St Louis.
Findings
The facility was found deficient in multiple life safety code areas including emergency preparedness planning, means of egress, delayed egress locking hardware, vertical openings enclosure, hazardous areas separation, fire alarm system installation, sprinkler system maintenance, exit requirements, fire drills, and fire protection features. Several deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (17)
E004 Emergency preparedness plan was incomplete and not updated annually. The facility census was 84 and policies to address identified hazards were missing.
K211 Means of egress were obstructed, including a designated emergency exit blocked by floor fans. The facility capacity was 100 and census was 78.
K222 Delayed egress locking hardware failed to release properly and lacked appropriate signage. The facility capacity was 100 and census was 78.
K311 Vertical openings enclosure was not maintained with required fire resistance rating, leaving unsealed holes in walls near stairwells and offices. The facility capacity was 100 and census was 78.
K321 Hazardous areas such as combustible storage rooms were not equipped with self-closing doors, potentially affecting 11 residents. The facility capacity was 100 and census was 78.
K324 Range hood filters were missing or improperly installed, and the range hood was not free of grease buildup, affecting kitchen safety. The facility capacity was 100 and census was 78.
K341 Fire alarm system failed to provide audible and visual notification in enclosed courtyards, affecting all occupants in those areas. The facility capacity was 100 and census was 78.
K353 Sprinkler system was not maintained properly, with heavy buildup of debris and paint on sprinkler heads, affecting 47 residents. The facility capacity was 100 and census was 78.
K932 Features of fire protection were deficient due to lint and debris buildup around laundry dryers, creating a fire hazard. The facility capacity was 100 and census was 78.
A2008 Hazardous areas were not properly separated by fire-resistant construction as required, referencing K321.
A2017 Range hood certification and maintenance requirements were not met, referencing K324.
A2018 Complete fire alarm system was not installed or maintained according to NFPA 101 standards, referencing K341.
A2034 Sprinkler system inspection and maintenance requirements were not met, referencing K353.
A2037 Exit requirements were not met, including insufficient unobstructed exits, referencing K211 and K222.
A2058 Fire drill and emergency preparedness plans were incomplete, and annual fire department consultation was not documented. The facility census was 78.
A2061 Fire drill evacuation requirements were not met, including lack of documented drills involving local fire department or emergency services. The facility census was 78.
A3001 The building was not substantially constructed or maintained in good repair, referencing K932.
Report Facts
Facility census: 78
Facility capacity: 100
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 7
Date: Jan 11, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations at Life Care Center of St Louis.
Findings
The facility was found deficient in developing and implementing baseline care plans within 48 hours for residents, providing adequate assistance with activities of daily living, and ensuring proper infection control and employee tuberculosis screening. Several residents did not receive timely or adequate care plan summaries or personal care services.
Deficiencies (7)
F655 Baseline Care Plan: The facility failed to complete baseline care plans within 48 hours for two residents and did not provide summaries of baseline care plans to eight residents or their representatives.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure staff provided necessary assistance with activities of daily living to three residents, including oral care and nail care.
A4029 Communicable Disease-Employees: The facility failed to implement procedures to ensure tuberculosis testing for newly hired employees was completed as required.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to implement interventions to prevent falls for one resident who sustained multiple falls with head injuries.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave.
A4075 Clean, Dry, Odor Free: Residents were not consistently clean, dry, and free of offensive odors, affecting their dignity and comfort.
A4076 Residents Groomed/Dressed Appropriately: Residents were not consistently well-groomed and dressed appropriately according to their preferences and medical conditions.
Report Facts
Facility census: 78
Number of sampled residents: 18
Number of residents with deficient baseline care plans: 10
Number of residents with ADL care deficiencies: 3
Number of new employees without TB testing: 4
Number of falls: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nerissa Pinkston | Surveyor | Named as surveyor conducting the inspection |
| LPN G | Unit Coordinator | Mentioned in relation to baseline care plan completion |
| Registered Nurse (RN) A | Unit Coordinator | Interviewed regarding baseline care plan completion |
| Director of Nursing | Director of Nursing | Interviewed regarding staff compliance and care plan audits |
| Licensed Practical Nurse (LPN) O | Licensed Practical Nurse | Interviewed regarding CNA reporting requirements |
| Certified Nurse Assistant (CNA) H | Certified Nurse Assistant | Observed providing care and interviewed about resident assistance |
| Certified Nurse Assistant (CNA) F | Certified Nurse Assistant | Observed providing care and interviewed about resident assistance |
| Registered Nurse (RN) N | Registered Nurse | Interviewed regarding TB screening and employee files |
Inspection Report
Plan of Correction
Census: 79
Deficiencies: 2
Date: Nov 8, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to respiratory care, specifically tracheostomy care and suctioning, including the use and management of BiPAP/CPAP devices for residents requiring respiratory support.
Findings
The facility failed to ensure proper respiratory care for a resident requiring BiPAP therapy, including lack of proper documentation, failure to follow physician orders, and inadequate staff communication. The resident was discharged following the incident, and a plan of correction was submitted addressing education, monitoring, and compliance with respiratory therapy orders.
Deficiencies (2)
F695 Respiratory care, including tracheostomy care and tracheal suctioning, was not provided according to professional standards and physician orders. The facility failed to ensure a bi-level positive airway pressure machine was properly managed and documented for one resident, leading to inadequate respiratory support.
A4074 Nursing care for residents was not provided in accordance with their condition and accepted nursing practice. This deficiency is linked to the respiratory care issues cited at F695.
Report Facts
Census: 79
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Documented resident's condition and respiratory status in nurse's notes | |
| Nurse B | Involved in resident care and communication regarding BiPAP machine removal | |
| Director of Nursing | Director of Nursing | Received contract for BiPAP machine and involved in communication about respiratory equipment |
| Executive Director | Executive Director | Scanned and emailed unsigned contract for BiPAP machine and responded to corporate communication |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 12
Date: Mar 5, 2018
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of St Louis following a survey completed on March 5, 2018. It addresses regulatory compliance issues identified during the inspection.
Findings
The facility failed to provide reasonable accommodations for resident needs, including access to call lights and appropriate liquid consistency for residents requiring thickened liquids. The facility also failed to complete required preadmission screenings and ensure proper medication storage and infection control practices.
Deficiencies (12)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure residents had access to call lights and appropriate liquids as ordered, affecting hydration and safety.
F645 PASARR Screening for MD & ID: The facility failed to complete required preadmission screening and resident review for one resident with a documented diagnosis of schizophrenia.
F761 Label/Store Drugs and Biologicals: The facility failed to secure medications properly, leaving medication carts unattended and medications unsecured during administration.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure food items were labeled, dated, stored properly, and that staff followed proper handwashing and sanitation procedures.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and use of personal protective equipment.
A4063 Medication Storage: The facility failed to store medications in a locked, safe, and orderly manner as required by regulation.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection and failed to report communicable diseases timely.
A6031 Kitchen Waste Containers: Waste containers used in food preparation and utensil washing areas were not kept covered when not in use.
A7002 Wash Hands/Arms & Clean Fingernails: Employees failed to wash hands and keep fingernails clean and trimmed as required.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to maintain proper food temperatures and protect food from contamination.
A7056 Nonfood Contact Surfaces, Cleaning: The facility failed to maintain nonfood contact surfaces in a clean and sanitary condition.
A7086 Equip/Utensils Air Dried, Self-Drain Utensils: Equipment and utensils were not properly air dried or stored in a self-draining position after sanitization.
Report Facts
Facility census: 73
Deficiencies cited: 12
Inspection Report
Life Safety
Census: 73
Capacity: 100
Deficiencies: 10
Date: Mar 5, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and related requirements at the Life Care Center of St Louis.
Findings
The facility was found deficient in several areas including door-locking arrangements on emergency exits, enclosure of vertical openings, fire alarm system installation, sprinkler system coverage and maintenance, smoke barriers, fire drills, and smoking regulations. These deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (10)
K222: The facility failed to ensure exit doors with door-locking arrangements opened as required and staff lacked knowledge of emergency exit codes. This affected emergency egress in two of 16 smoke compartments.
K311: The facility failed to maintain enclosure of vertical openings with required fire resistance rating, leaving multiple unsealed conduit penetrations in barrier walls on various floors.
K321: The facility failed to provide self-closing devices on hazardous area doors, leaving doors held open by magnets and not connected to fire alarm system.
K341: The facility failed to install and maintain complete fire alarm system coverage in the elevator shaft, with no smoke detector coverage in the elevator shaft.
K351: The facility failed to provide complete sprinkler coverage in the elevator hoistway, with no sprinkler coverage under or at the top of the hoistway and hydraulic fluid spills present.
K353: The facility failed to ensure quarterly inspections and annual inspection of the sprinkler system were performed and documented.
K372: The facility failed to maintain smoke barriers to resist passage of smoke and seal penetrations with fire resistance rating of at least one hour.
K712: The facility failed to conduct fire drills under varied times and unexpected conditions on all shifts, affecting preparedness of staff.
K741: The facility failed to maintain smoking regulations, including ashtrays and proper disposal of cigarette butts, leading to fire hazards in smoking and non-smoking areas.
K932: The facility failed to ensure the boilers had current safety inspections as required by state regulations.
Report Facts
Facility capacity: 100
Census: 73
Smoke compartments: 16
Residents affected: 28
Fire drills: 4
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