Inspection Reports for
McClay Senior Care
3801 MCCLAY ROAD, SAINT PETERS, MO, 63376-7327
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
47 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 5
Date: Apr 4, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to conduct weekly skin assessments and complete Braden Scale evaluations for residents at risk of pressure ulcers, leading to deterioration of wounds and inadequate documentation and treatment.
Complaint Details
The investigation was complaint-driven based on allegations of inadequate pressure ulcer care and failure to prevent new ulcers. The complaint was substantiated with findings of actual harm to residents.
Findings
The facility failed to complete admission and weekly skin assessments and Braden Scale evaluations for multiple residents, resulting in worsening pressure ulcers including Stage III ulcers. Documentation of wounds, physician notifications, and treatment orders were incomplete or missing. The facility did not consistently implement prevention protocols such as use of pressure-relieving devices and turning schedules. Several residents had unreported or untreated wounds, and the facility's wound care policies were not fully followed.
Deficiencies (5)
Failure to conduct weekly skin assessments and complete Braden Scale for residents at risk of pressure ulcers.
Failure to document admission skin assessment indicating existing pressure ulcers and wound characteristics.
Failure to notify physician and obtain treatment orders for wounds.
Failure to implement pressure ulcer prevention protocols including use of pressure-relieving devices and turning.
Failure to document wound care treatments and monitor healing progress.
Report Facts
Residents affected: 4
Facility census: 47
Stage III pressure ulcers: 2
Pressure ulcer measurements: 12
Pressure ulcer measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Admitting nurse who failed to complete admission skin assessment and document wounds. |
| CNA D | Certified Nurse Aide | Reported resident had sores on knees and sacrum; completed skin assessments during showers. |
| RN E | Registered Nurse | Noted wound nurse awareness and lack of skin assessments. |
| NP A | Nurse Practitioner | Contracted wound care provider who assessed resident's Stage III pressure ulcer and ordered treatment. |
| LPN B | Licensed Practical Nurse | Documented skin observations and notified physician for low air loss mattress order. |
| Director of Nursing | Director of Nursing | Acknowledged skin assessments should be done on admission and weekly; aware of wounds but did not see resident's skin. |
Inspection Report
Routine
Census: 48
Deficiencies: 3
Date: Apr 2, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration, medication storage, food safety, and sanitation standards at McClay Senior Care.
Findings
The facility failed to ensure residents were free from significant medication errors related to insulin administration, failed to properly store and dispose of medications including controlled substances, and did not maintain proper food safety and sanitation practices including personal hygiene, handwashing, food storage, and cleanliness of equipment.
Deficiencies (3)
Failed to prime insulin pens and hold needle for required time, resulting in administration of less than ordered insulin dose to three residents.
Failed to keep lorazepam behind two locks and failed to remove and destroy discharged resident medications, with medications remaining up to 671 days after discharge.
Failed to store, prepare, and serve food in accordance with professional standards including improper hair restraint use, inadequate handwashing and glove use, consumption of personal food and beverages in food prep areas, improper handling of utensils and food containers, and unsanitary storage of food items.
Report Facts
Residents affected by insulin medication errors: 3
Facility census: 48
Days medications remained after resident discharge: 671
Number of discharged residents with medications not destroyed: 8
Size of ceiling vent with debris: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in insulin medication administration errors |
| CMT I | Certified Medication Technician | Named in insulin medication administration errors |
| Licensed Practical Nurse J | Licensed Practical Nurse | Provided statements on insulin administration and medication destruction practices |
| Director of Nursing | Director of Nursing | Provided expectations on insulin administration and medication destruction |
| Dietary Manager | Dietary Manager | Provided statements on food safety, hygiene, and cleaning practices |
| Dietary Aide E | Dietary Aide | Observed with improper hair restraint and hygiene practices |
| Dietary Aide D | Dietary Aide | Observed with improper hair restraint and hygiene practices |
| Dietary Aide F | Dietary Aide | Observed consuming personal beverage in food prep area and improper hygiene |
| Certified Nurse Assistant G | Certified Nurse Assistant | Observed with improper hair restraint and hygiene practices during food service |
| Registered Nurse M | Registered Nurse | Provided statements on medication storage and destruction responsibilities |
Inspection Report
Routine
Census: 50
Deficiencies: 3
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, fall risk assessment and prevention, and food safety in the nursing facility.
Findings
The facility failed to administer medications as ordered for two residents, failed to properly assess and intervene after resident falls for two residents, and failed to serve food at safe and appetizing temperatures. The facility census was 50 residents.
Deficiencies (3)
Failure to administer medication as ordered by the physician for two residents.
Failure to assess residents, implement 72-hour observations, or put interventions in place after falls for two residents.
Failure to provide food items at safe and appetizing temperatures.
Report Facts
Facility census: 50
Medication administration omissions: 9
Fall incidents: 3
Food temperatures: 110
Food temperatures: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Described medication order review and fall assessment procedures | |
| Director of Nursing | Provided expectations for medication administration and fall assessments | |
| Administrator | Provided expectations for medication administration, fall assessments, and food temperature policies | |
| Dietary Manager (DM) | Responsible for food preparation and temperature monitoring | |
| LPN/MDS Coordinator | Described fall documentation and care plan update responsibilities |
Inspection Report
Routine
Census: 48
Deficiencies: 13
Date: Aug 29, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents' needs and preferences, failure to ensure resident rights and self-determination, failure to follow professional standards in medication administration, failure to maintain resident privacy, failure to provide appropriate pressure ulcer care, failure to provide necessary assistance with activities of daily living, failure to maintain sanitary kitchen conditions, failure to maintain accurate resident records, failure to implement infection prevention and control measures, and failure to ensure a working call light system with timely response.
Deficiencies (13)
Failure to provide reasonable accommodations of needs and preferences of residents related to call light accessibility and preferences for getting out of bed.
Failure to honor residents' rights to self-determination including choice of bathing and time to awaken or be out of bed.
Failure to ensure resident privacy during personal care, including failure to close blinds during catheter care.
Failure to follow professional standards in medication administration including levothyroxine timing, insulin pen administration, PICC line dressing changes, and ace wrap application.
Failure to provide necessary assistance with activities of daily living to maintain personal hygiene and prevent body odor.
Failure to reposition residents at risk for pressure ulcers and failure to complete skin assessments as ordered.
Failure to ensure resident safety including use of gait belts during transfers, proper placement of wheelchair foot pedals, and stopping transfers causing pain.
Failure to provide appropriate catheter care including hand hygiene, securing catheter tubing, and maintaining urinary drainage bag below bladder level.
Failure to implement gradual dose reductions and proper documentation for psychotropic medications and failure to limit PRN psychotropic drug orders to 14 days.
Failure to maintain sanitary kitchen conditions including food debris, unlabeled and undated food items, and improper hairnet use.
Failure to maintain complete and accurate resident records as demonstrated by shower documentation signed by staff who did not provide care.
Failure to ensure infection prevention and control including hand hygiene, appropriate PPE use, and maintaining urinary catheter bag off the floor.
Failure to ensure a working call light system with timely response to call lights for residents.
Report Facts
Call light response time: 161
Call light response time: 95
Call light response time: 93
Call light response time: 48
Call light response time: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT R | Certified Medication Technician | Named in medication administration and transfer pain findings |
| CNA S | Certified Nurse Assistant | Named in catheter care, call light response, and infection control findings |
| RN P | Registered Nurse | Named in catheter care and infection control findings |
| LPN D | Licensed Practical Nurse | Named in oxygen administration and infection control findings |
| CNA T | Certified Nurse Assistant | Named in transfer without gait belt finding |
| CNA U | Certified Nurse Assistant | Named in transfer without gait belt finding |
| COTA E | Certified Occupational Therapy Assistant | Named in wheelchair foot pedal use finding |
| LPN F | Licensed Practical Nurse | Named in wheelchair foot pedal use and call light system findings |
| CNA E | Certified Nurse Assistant | Named in hand hygiene and incontinence care findings |
| NA K | Nurse Assistant | Named in PPE use findings |
| CNA AA | Certified Nurse Assistant | Named in PPE use findings |
| RN M | Registered Nurse | Named in call light system findings |
| CNA Z | Certified Nurse Assistant | Named in call light system findings |
| LPN G | Licensed Practical Nurse | Named in call light system findings |
| Administrator | Named in call light system and PPE use findings | |
| Director of Nursing | Named in multiple findings including catheter care, transfers, call light system, and PPE use |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 18
Date: Nov 26, 2019
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, financial management, abuse prevention, medication administration, infection control, and other regulatory compliance issues at McClay Senior Care.
Complaint Details
The complaint investigation included allegations of financial mismanagement, failure to provide required notices, abuse and neglect reporting deficiencies, medication errors, infection control lapses, inadequate care and supervision, and failure to follow vaccination protocols.
Findings
The facility was found deficient in multiple areas including failure to manage resident funds properly, failure to reconcile resident trust accounts, failure to notify residents or estates of funds after death, failure to provide required Medicare notices, inadequate abuse reporting policies, failure to report injuries of unknown origin, incomplete investigations, failure to complete significant change assessments, inadequate personal care and hygiene, pressure ulcer care deficiencies, unsafe resident transfers and fall prevention, medication management issues including crushing extended release medications, infection control lapses, incomplete facility assessment, failure to properly screen and vaccinate residents for tuberculosis and pneumococcal disease, and failure to follow dietary menus and food portioning.
Deficiencies (18)
Failure to ensure resident funds were held in interest bearing accounts separate from facility operating accounts and failure to notify residents of funds.
Failure to maintain complete accounting and reconciliation of resident trust funds and failure to provide monthly personal spending allowances.
Failure to provide final accounting of resident funds within 30 days after discharge or death.
Failure to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare Part A benefits ended or reduced.
Failure to develop and implement written policies to report abuse and neglect within required timeframes.
Failure to report injuries of unknown origin to the state agency and incomplete investigations.
Failure to complete significant change in status assessments for residents with physical or mental decline.
Failure to provide adequate personal care and hygiene for dependent residents.
Failure to document and provide appropriate pressure ulcer care including weekly reassessment and care plan updates.
Failure to ensure resident safety during transfers and falls, failure to update care plans and implement fall prevention interventions after falls.
Failure to properly label insulin pens with date opened and failure to discard expired insulin.
Failure to follow pharmacy consultant recommendations and failure to limit PRN psychotropic medications to 14 days without physician review.
Failure to properly label opened insulin pens and stock insulin bottles with date opened.
Failure to follow proper sanitation and food handling practices in the kitchen including dirty equipment and improper dish storage.
Failure to conduct and update a comprehensive facility assessment to ensure adequate staffing and resources for resident care.
Failure to follow infection control practices including hand hygiene, glove changes, and proper cleaning of glucometers between residents.
Failure to complete two-step tuberculin skin testing (TST) for residents upon admission and failure to document results.
Failure to maintain and follow policies and procedures for pneumococcal vaccination including failure to screen, offer, document, and administer vaccines per CDC guidelines.
Report Facts
Residents affected by financial mismanagement: 27
Facility census: 53
Weight loss percentage: 11.06
Medication administration days: 14
Insulin pen expiration: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency related to improper glove use and hand hygiene during resident care. |
| CMT A | Certified Medication Technician | Named in infection control deficiency related to improper glucometer cleaning and insulin administration. |
| RN H | Registered Nurse | Named in medication and fall investigation deficiencies. |
| DON | Director of Nursing | Named in multiple deficiencies including medication management, vaccination screening, and facility assessment. |
| Dietary Aide Q | Dietary Aide | Named in dietary portioning and menu compliance deficiencies. |
| Registered Dietitian | Dietitian | Named in dietary monitoring and weight loss management deficiencies. |
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