Inspection Reports for
Life Care Center of St Louis
3520 CHOUTEAU AVE, SAINT LOUIS, MO, 63103-2916
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
90% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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
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
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
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
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