Deficiencies (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
16
12
8
4
0
Occupancy
Latest occupancy rate
90% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
A recertification and complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services to assess compliance with 42 CFR 483 subpart B.
Complaint Details
The survey was a recertification and complaint survey. The complaint was related to drug regimen review irregularities. The deficiency was substantiated based on interviews, record review, and facility policy review.
Findings
The facility was found not to be in substantial compliance due to failure to ensure the pharmacist completed monthly medication reviews in a timely manner for one of five sampled residents. The pharmacist was not linked to the resident's chart to review medications monthly.
Deficiencies (1)
F756 Drug Regimen Review. The facility failed to ensure the pharmacist completed the monthly medication reviews (MMR) timely for one of five sampled residents, as the pharmacist was not linked to the resident's chart to complete the MMR.
Report Facts
Survey Census: 43
Sample Size: 14
Residents reviewed for medication review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean L. Badwell | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed confirming pharmacist completion of medication reviews |
Inspection Report
Life Safety
Census: 43
Capacity: 48
Deficiencies: 4
Date: Sep 11, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including fire rated door assemblies not latching, incomplete quarterly sprinkler inspections, improper fire door inspections and documentation, and failure to complete a required load bank test on the emergency generator.
Deficiencies (4)
K227: The facility failed to ensure the fire rated door assembly protecting the exit passageway latched when closed. The stairway door going into the exit passageway did not latch when closed.
K353: The facility failed to ensure quarterly sprinkler inspections were conducted as required. Inspection records for the first and second quarters of 2024 were not completed.
K761: The facility failed to ensure fire doors were inspected correctly by qualified individuals and that inspections were properly documented. Fire door rating tags were painted over and not legible.
K918: The facility failed to ensure a load bank test was completed on the emergency generator every 36 months. Records showed it had been over 36 months since the last test.
Report Facts
Occupied beds: 44
Licensed beds: 48
Residents affected: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean L. Badwell | Administrator | Signed the initial statement of deficiencies |
| Wayne Sprinkler | Conducted the Quarter 3 Sprinkler Inspection | |
| Maintenance Director | Confirmed fire door latch and sprinkler inspection issues during interviews | |
| Director of Maintenance | Confirmed quarterly sprinkler inspections were not completed and load bank test was overdue |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Sep 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to quality of care, specifically regarding a resident's hypoglycemic episode and medication administration errors.
Complaint Details
The complaint investigation found the violation to be at the immediate and serious jeopardy level "J" for F684 and at an imminent danger class I level for A4075. The facility implemented corrective actions during the onsite visit and submitted a plan of correction. A revisit/final revisit will be conducted to determine compliance.
Findings
The facility failed to provide adequate care to a resident experiencing a hypoglycemic episode, including failure to notify the physician of condition changes, failure to report medication errors, and inadequate monitoring. The resident subsequently died. The facility's policies and procedures related to insulin administration, hypoglycemia management, and medication errors were reviewed and found deficient.
Deficiencies (2)
F684 Quality of Care - The facility failed to provide services to promote the highest practicable physical well-being for a resident experiencing hypoglycemia, including failure to notify the physician of condition changes and medication errors, and inadequate monitoring.
A4075 Nursing Care per Resident Condition - The facility failed to provide personal attention and nursing care consistent with the resident's condition, as evidenced by the deficiencies cited at F684.
Report Facts
Census: 44
Resident sample size: 6
Blood sugar levels: 35
Blood sugar levels: 169
Completion date: Oct 13, 2023
Inspection Report
Plan of Correction
Census: 24
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a complaint investigation of abuse and neglect at St Louis Altenheim.
Complaint Details
The complaint investigation was substantiated based on video evidence and interviews. The alleged perpetrator was relieved of duties and no longer employed by the facility.
Findings
The facility failed to ensure a resident was free from physical and verbal abuse by a Certified Medication Technician (CMT C), who forcibly moved the resident's wheelchair and physically grabbed the resident's wrist. The facility conducted an investigation, terminated the employee, and corrected the deficiency.
Deficiencies (1)
F 600: The facility failed to protect a resident from verbal and physical abuse by a Certified Medication Technician who forcibly moved the resident's wheelchair, grabbed the resident's wrist, and caused emotional distress.
Report Facts
Facility census: 24
Date of incident: Mar 24, 2023
Date of correction: Mar 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named as the alleged perpetrator in the abuse incident |
| Nurse D | Responded to incident, assessed resident, and separated CMT C from resident | |
| Administrator | Administrator | Notified of incident, coordinated investigation and reporting |
| Director of Nursing | Director of Nursing | Informed by Administrator and involved in investigation |
| CNA E | Certified Nursing Assistant | Witnessed incident and reported yelling and distress |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 11/10/2020 through 11/17/2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Feb 21, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for nursing home facility St Louis Altenheim.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, comprehensive care plans, activities of daily living, medication administration, infection control, and food safety. Several deficiencies were classified with severity levels ranging from Class II to Class III.
Deficiencies (9)
F641 Accuracy of Assessments CFR(s): 483.20(g). The facility failed to accurately code the Minimum Data Set for resident #2, missing diagnoses and behaviors.
F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1). The facility failed to update resident care plans to include behaviors and vision impairments for residents #2 and #9.
F676 Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii). The facility failed to assess and provide language and auditory assistive devices for resident #60 and address multiple ADL-related problems.
F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2). The facility failed to provide adequate nail care for residents #3 and #4.
F688 Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3). The facility failed to provide restorative therapy assessment and evaluation for resident #4.
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2). The facility failed to ensure the resident environment remained free of accident hazards and failed to properly store medications.
F730 Nurse Perform Review-12 hr/yr In-Service CFR(s): 483.35(d)(7). The facility failed to ensure certified nurse aides received required 12 hours of in-service training.
F758 Free from Unnec Psychotropic Meds/PRN Use CFR(s): 483.45(c)(3)(e)(1)-(5). The facility failed to re-evaluate psychotropic medications after 14 days for residents #1, #3, and others.
F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f). The facility failed to maintain an effective infection prevention program and failed to maintain food safety and TB testing compliance.
Report Facts
Census: 24
Certified beds: 9
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 21, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and licensure requirements for the facility.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code with no deficiencies cited. No state licensure deficiencies were found during this inspection.
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 2
Date: Aug 12, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding an elopement incident involving a cognitively impaired resident who left the facility unsupervised.
Complaint Details
The complaint investigation was substantiated based on the elopement of a cognitively impaired resident on 7/14/19. The resident left the chapel unsupervised, exited through an unalarmed door, and was found outside the facility approximately 12 minutes later. The facility failed to address elopement risk in the resident's care plan and did not maintain effective alarm systems or staff supervision.
Findings
The facility failed to provide adequate supervision and protective oversight for a cognitively impaired resident, resulting in an elopement incident. The investigation revealed deficiencies in staff response, alarm system functionality, and resident safety protocols.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision for a cognitively impaired resident who eloped unsupervised for approximately 12 minutes.
A4073 Protective Oversight, Voluntary Leave: The facility did not provide twenty-four hour protective oversight and supervision for residents on voluntary leave, as evidenced by the elopement incident.
Report Facts
Resident census: 16
Temperature: 91
Vital signs: Blood pressure 110/68, pulse 80, respirations 20, temperature 98.6, oxygen saturation 94%
Inspection Report
Plan of Correction
Census: 13
Capacity: 18
Deficiencies: 4
Date: Mar 22, 2019
Visit Reason
The document is a Plan of Correction submitted by St Louis Altenheim following a survey conducted on 03/22/2019. It addresses deficiencies cited during the inspection related to care plan timing, professional standards, medication labeling and storage, and infection prevention and control.
Findings
The facility was found deficient in revising care plans to reflect current resident needs, meeting professional standards for services, labeling and storing medications properly, and maintaining infection prevention and control procedures. Specific issues included failure to update care plans for wound treatments and hospice services, lack of diagnoses for antibiotic use, improper labeling of insulin vials, and inadequate hand hygiene practices.
Deficiencies (4)
F 657 Care Plan Timing and Revision: The facility failed to revise care plans to reflect current resident needs and corresponding interventions for two residents, including wound treatments and hospice services.
F 658 Services Provided Meet Professional Standards: The facility failed to ensure services met professional standards and physician's orders were followed, including obtaining diagnoses for antibiotic use and applying prescribed treatments.
F 761 Label/Store Drugs and Biologicals: The facility failed to label insulin vials and flexpens with date opened, expiration date, and resident name, and did not maintain proper policies for insulin storage.
F 880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program, including proper hand hygiene and peri-care procedures, leading to risk of infection transmission.
Report Facts
Census: 13
Total Capacity: 18
Deficiency Count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Oswald | Administrator | Signed the report and plan of correction |
| Sue Weber | Pharmacist Consultant | Instructed pharmacy staff on antibiotic dispensing per plan of correction |
| Director of Nursing | Interviewed regarding antibiotic diagnosis and medication labeling |
Inspection Report
Life Safety
Census: 18
Capacity: 24
Deficiencies: 4
Date: Mar 22, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to evaluate the facility's compliance with fire safety and sprinkler system regulations.
Findings
The facility failed to provide complete sprinkler coverage in certain areas, maintain sprinkler heads free of debris and damage, prohibit improper use of power strips, and properly separate and label oxygen tanks. These deficiencies had the potential to affect residents and occupants.
Deficiencies (4)
K351 Sprinkler System - Installation: The facility failed to provide sprinkler coverage in the closet near the boiler room entrance and an exterior storage room, potentially affecting occupants on the ground floor.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of debris and ensure escutcheon plates fit tightly, with multiple sprinkler heads dusty, rusted, or with paint, potentially affecting all residents.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit the use of extension cords for more than temporary use and ensure power strips were not used improperly, with multiple violations observed in various offices.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to separate full and empty oxygen tanks and maintain proper signage, potentially affecting occupants on the second floor.
Report Facts
Facility capacity: 24
Resident census: 18
Certified beds census: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Arnold | LNHA Administrator | Signed the report and plan of correction |
| Maintenance Director | Interviewed regarding sprinkler system and oxygen tank storage | |
| Administrator | Interviewed regarding power strip use and oxygen tank storage |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jun 19, 2018
Visit Reason
Annual survey conducted to assess compliance with federal regulations for nursing home facility St Louis Altenheim.
Findings
The facility was found deficient in multiple areas including resident rights, care plan revisions, nurse aide training, medication errors, and environmental conditions. Several residents' care plans were not updated timely, and staff failed to maintain respectful behavior and proper medication administration.
Deficiencies (10)
F550 Resident Rights: Facility failed to ensure staff treated residents with respect and dignity, evidenced by a loud verbal argument involving staff and disrespectful behavior toward residents.
F657 Care Plan Timing and Revision: Facility failed to revise care plans with new interventions for five of eight sampled residents, including falls, oxygen, diet orders, and hospice services.
F730 Nurse Aide Performance Review: Facility failed to provide required annual in-service education for certified nurse aides, with no documentation of training hours or performance reviews for four CNAs.
F759 Medication Errors: Facility failed to ensure medication error rate was less than 5%, with a 29.41% error rate observed in 34 medication opportunities.
F921 Safe/Functional/Sanitary/Comfortable Environment: Facility failed to maintain kitchen cleanliness, with grease buildup and grime on equipment and surfaces during multiple days of the survey.
A4024 In-service Training-Nursing Personnel: Facility failed to ensure a system of in-service training for nursing personnel related to problems, needs, care of residents, and infection control.
A4029 Communicable Disease-Employees: Facility failed to properly complete screening for tuberculosis testing of employees on their date of hire.
A4054 Safe/Effective Medication System: Facility failed to maintain a safe and effective system of medication distribution, administration, control, and use.
A7067 Nonfood Contact Surfaces Cleaned as Needed: Facility failed to clean nonfood-contact surfaces of equipment as necessary to keep them free of dust, dirt, food particles, and debris.
A8030 Dignity/Privacy: Facility failed to ensure residents were treated with consideration, respect, and full recognition of dignity and individuality.
Report Facts
Census: 20
Medication error rate: 29.41
Certified nurse aides: 13
Inspection Report
Life Safety
Census: 20
Capacity: 24
Deficiencies: 5
Date: Jun 19, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and related provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association.
Findings
The facility failed to meet several Life Safety Code requirements including insufficient corridor width, fire alarm system being out of service, inadequate fire watch policies during system outages, failure to maintain smoke barrier doors, and lack of a remote manual stop station for the emergency generator.
Deficiencies (5)
K232: The facility failed to have corridors serving as exit access at least 8 feet in width, affecting safety of all residents.
K346: The fire alarm system was out of service for more than 4 hours without an adequate fire watch policy, risking occupant safety.
K354: The sprinkler system was out of service without an adequate fire watch policy and communication procedures during outages.
K374: The facility failed to maintain smoke barrier doors so they closed properly upon fire alarm activation, risking occupant safety.
K918: The emergency generator lacked a remote manual stop station, risking inability to quickly stop the generator in emergencies.
Report Facts
Facility capacity: 24
Resident census: 20
Certified beds census: 12
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