Inspection Reports for
St Peters Rehab and Healthcare Center
230 SPENCER RD, SAINT PETERS, MO, 63376-2425
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
30.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
449% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
81% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by a Certified Nurse Aide (CNA B) on 08/25/2025.
Complaint Details
The complaint investigation substantiated that CNA B physically abused Resident #1 on 08/25/2025 by handling the resident roughly, causing bruising and emotional distress. The resident and multiple staff members confirmed the abuse. CNA B was terminated and corrective actions were implemented.
Findings
The facility failed to protect Resident #1 from physical abuse by CNA B, who aggressively moved the resident causing bruising and distress. The abuse was confirmed through interviews, observations, and documentation, leading to CNA B's termination and staff education on abuse prevention.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from physical abuse when CNA B aggressively moved the resident in bed causing bruising and emotional distress. The resident was scared and did not want CNA B to provide care again.
Report Facts
Facility census: 78
Bruise measurements: 10
Bruise measurements: 6
Bruise measurements: 4
Bruise measurements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Witnessed abuse, intervened to stop CNA B, provided statements, and comforted the resident |
| CNA B | Certified Nurse Aide | Perpetrator of physical abuse against Resident #1, terminated after incident |
| CNA C | Certified Nurse Aide | Witnessed abuse and assisted in caring for the resident after CNA B was removed |
| CMT D | Certified Medication Technician | Assisted in caring for the resident after CNA B was removed |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted due to complaints and concerns raised by residents regarding prolonged call light wait times and inadequate staff response, as well as issues related to fall management and response to resident falls.
Complaint Details
The investigation was triggered by complaints from residents about call lights not being answered promptly or being turned off without assistance, and a grievance filed regarding a resident who fell and waited up to an hour for help. The complaint was substantiated with findings of delayed staff response and inadequate fall management documentation.
Findings
The facility failed to adequately respond to resident call light concerns over multiple months, with documented delays in staff response and unresolved resident complaints. Additionally, the facility did not follow its fall management and response policies for a resident who sustained multiple falls, including failure to assess, document, and notify responsible parties timely.
Deficiencies (2)
F 0565: The facility failed to respond and provide feedback to resident council concerns about call light wait times and staff response over several months, despite repeated complaints and documented grievances.
F 0689: The facility failed to follow fall management and response policies for Resident #9, who sustained two falls with no timely documentation, assessment, or notification to physician and responsible parties.
Report Facts
Facility census: 93
Call light wait times: 30
Call light wait times: 45
Call light wait times: 120
Fall dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Involved in fall documentation and assessment for Resident #9 |
| LPN F | Licensed Practical Nurse | Responded to Resident #9 fall and communicated with RN G |
| RN D | Registered Nurse | Assessed Resident #9 after fall and documented injuries |
| Assistant Director of Nursing | ADON | Interviewed regarding fall incident and documentation |
| Certified Nurse Aide A | CNA | Observed call light issues and resident care |
| Certified Nurse Aide B | CNA | Provided incontinent care after delayed call light response |
| Certified Nurse Aide C | CNA | Assisted Resident #9 off floor after fall |
| Activity Director | Documented resident council concerns and communicated with departments | |
| Administrator | Provided statements on expectations for call light response and resident concerns |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation focusing on infection prevention and control practices at St Peters Rehab and Healthcare Center.
Complaint Details
The complaint investigation focused on infection prevention and control practices related to residents with wounds, indwelling catheters, and enteral feedings. The complaint was substantiated based on observations and record reviews showing failures in hand hygiene, PPE use, and signage for Enhanced Barrier Precautions.
Findings
The facility failed to ensure nursing staff performed appropriate hand hygiene and used personal protective equipment (PPE) correctly while providing care to residents on Enhanced Barrier Precautions (EBP). Multiple residents with wounds, indwelling catheters, and enteral tube feedings were observed, and staff did not follow facility policies for infection control.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to ensure nursing staff performed appropriate hand hygiene and used PPE correctly when providing care to residents on Enhanced Barrier Precautions. Observations showed staff did not wear gowns or gloves as required and did not post proper signage on resident doors.
A4086 Infection Control/Communicable Disease: The facility failed to report residents diagnosed with communicable diseases to the Missouri Department of Health within seven days as required by state regulations.
Report Facts
Facility census: 81
Residents with wounds: 16
Residents with indwelling catheters: 6
Residents receiving enteral tube feedings: 3
Residents with pressure ulcers: 15
Residents with urinary tract infections: 5
Residents with wound infections: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | Certified Nurse Aide | Named in observation of failure to wear gowns and gloves and improper hand hygiene |
| Certified Nurse Aide C | Certified Nurse Aide | Named in observation of failure to wear gowns and gloves and improper hand hygiene |
| Certified Nurse Aide D | Certified Nurse Aide | Observed failing to remove gloves and wash hands properly during care |
| Registered Nurse E | Registered Nurse | Observed providing care without proper PPE and hand hygiene |
| Assistant Director of Nursing/Infection Preventionist | Assistant Director of Nursing/Infection Preventionist | Placed signage on resident doors and provided infection control guidance |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control policies and staff expectations |
| Administrator | Administrator | Interviewed regarding staff compliance with hand washing and EBP policies |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control policies, specifically focusing on hand hygiene and the use of Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling catheters, and enteral tube feedings.
Findings
The facility failed to ensure nursing staff performed appropriate hand hygiene and use of PPE during care for residents on EBP. Observations showed staff did not wear gowns or change gloves properly, and EBP signage was often missing. Several residents with wounds, catheters, and infections were not properly managed according to facility policy.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff did not perform proper hand hygiene or use PPE during care for residents on Enhanced Barrier Precautions.
Report Facts
Facility census: 81
Residents with wounds: 16
Residents with indwelling catheters: 6
Residents receiving enteral tube feedings: 3
Residents with pressure ulcers: 15
Residents with urinary tract infections: 3
Residents with wound infections: 5
Residents with urinary tract infections: 5
Residents with indwelling catheters: 8
Residents with enteral feeding: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Observed providing care without proper gown use and interviewed regarding EBP compliance |
| CNA B | Certified Nurse Aide | Observed providing care without PPE and interviewed about EBP awareness |
| CNA D | Certified Nurse Aide | Observed providing care without proper PPE and interviewed about EBP knowledge |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Responsible for infection control program and interviewed about EBP implementation |
| Director of Nursing | Director of Nursing | Interviewed about staff expectations for hand hygiene and EBP compliance |
| Administrator | Administrator | Interviewed about expectations for staff compliance with hand hygiene and EBP |
Inspection Report
Plan of Correction
Census: 87
Deficiencies: 4
Date: Nov 27, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for St Peters Rehab and Healthcare Center following a survey completed on 11/27/2024. It addresses deficiencies found during the inspection related to resident care and safety.
Findings
The facility failed to meet professional standards in comprehensive care plans, including failure to clarify and obtain physician orders for residents with surgical wounds and failure to complete neurological checks after falls. The facility also failed to provide adequate supervision to prevent injury and failed to respond timely to call lights for several residents.
Deficiencies (4)
F658: The facility failed to clarify and obtain physician orders for two residents with surgical wounds and failed to complete neurological checks per policy following a fall for one resident. Documentation and assessments related to wound care and neurological monitoring were incomplete or missing.
F689: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent injury for one resident who fell in the shower room. The facility did not respond timely to call lights for three residents.
F919: The facility failed to provide an adequate resident call system and failed to respond to call lights in a timely manner for multiple residents, resulting in delayed assistance.
A4075: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice as evidenced by deficiencies in care plans and nursing interventions.
Report Facts
Facility census: 87
Number of sampled residents: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Documented nursing progress notes and interviewed regarding Resident #1 |
| LPN C | Licensed Practical Nurse | Documented wound care nursing notes and interviewed regarding Resident #1 and #2 |
| Assistant Director of Nursing | ADON | Interviewed regarding skin assessment and wound care policies |
| Director of Nursing | DON | Interviewed regarding skin assessment, wound care, and call light response policies |
| Nurse Aide D | Nurse Aide | Interviewed regarding shower assistance and resident falls |
| Registered Nurse F | RN | Interviewed regarding call light response times |
| Administrator | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Routine
Census: 87
Deficiencies: 3
Date: Nov 27, 2024
Visit Reason
Routine inspection of St Peters Rehab and Healthcare Center to assess compliance with professional standards of quality, resident safety, and call system responsiveness.
Findings
The facility failed to clarify and obtain physician orders for surgical wound care for two residents admitted post-surgery and failed to complete neurological checks after a fall for one resident. The facility also failed to provide adequate supervision to prevent a resident fall in the shower and failed to respond promptly to call lights for three residents.
Deficiencies (3)
F 0658: The facility failed to clarify and obtain physician orders for surgical wound care for two residents admitted post-surgery and failed to complete neurological checks per policy following a fall for one resident.
F 0689: The facility failed to provide adequate supervision, resulting in a resident being left unattended in the shower and sustaining a right hip fracture.
F 0919: The facility failed to respond to call lights in a timely manner for three residents, with documented delays ranging from 15 minutes to over an hour.
Report Facts
Facility census: 87
Call light activation durations: 87
Neurological checks required: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Documented nursing progress notes and interviewed regarding Resident #1's wound care and admission |
| LPN C | Wound Care Nurse | Provided wound care notes and interviewed regarding wound care policies and Resident #1 and #2 |
| Nurse Aide D | Nurse Aide | Assigned staff who left Resident #2 unattended in shower leading to fall |
| LPN A | Licensed Practical Nurse | Interviewed regarding call light response expectations |
| RN F | Registered Nurse | Interviewed regarding call light response expectations |
| Assistant Director of Nursing | ADON | Interviewed regarding wound care and supervision policies |
| Director of Nursing | DON | Interviewed regarding wound care, supervision, and call light response policies |
| Administrator | Administrator | Interviewed regarding facility expectations for wound care, supervision, and call light response |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 6
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and comfortable environment; failure to follow physician orders for medication administration; inadequate assistance with activities of daily living; insufficient nutritional interventions; inadequate nursing staffing and oversight; and failure to ensure food was served palatably and at safe temperatures. The census during the inspection was 81 residents.
Deficiencies (6)
F 0584: The facility failed to provide a safe, clean, and comfortable environment by not ensuring resident rooms and living spaces were clean and in good repair.
F 0658: The facility failed to follow physician orders for three residents, including missed insulin administration and lack of physician notification for abnormal blood sugar.
F 0677: The facility failed to provide necessary care and assistance with activities of daily living for two residents, affecting grooming and personal hygiene.
F 0692: The facility failed to provide interventions to address weight loss and follow dietician recommendations for two residents.
F 0725: The facility failed to provide adequate nursing staff and oversight to meet residents' hygiene needs and respond to call lights timely for multiple residents.
F 0804: The facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature.
Report Facts
Facility census: 81
Sampled residents reviewed: 25
Residents affected by missed insulin: 3
Residents affected by ADL care failure: 2
Residents affected by staffing and call light response: 8
Inspection Report
Routine
Census: 82
Deficiencies: 8
Date: Apr 12, 2024
Visit Reason
Routine inspection of St Peters Rehab and Healthcare Center to assess compliance with regulatory requirements including resident rights, accommodation of needs, environment, abuse prevention, medication administration, nutrition, staffing, and food service.
Findings
The facility was found deficient in multiple areas including failure to protect resident rights, inadequate supply of bariatric briefs, poor cleanliness and odor control, abuse and neglect of residents, failure to follow physician medication orders, inadequate hydration and nutrition assessments, insufficient nursing staffing, and failure to provide condiments with meals.
Deficiencies (8)
F 0551: The facility failed to ensure residents retained their right to exercise their rights, including the right to communicate and make decisions, as evidenced by interference with Resident 73's phone and contacts despite cognitive intactness.
F 0558: The facility failed to provide bariatric incontinent briefs in ample supply to meet the needs of three residents (R4, R14, R20), resulting in use of improperly sized briefs and discomfort.
F 0584: The facility failed to provide a safe, clean, and comfortable environment, with strong urine odors, dirty floors, unclean resident rooms, and inadequate housekeeping staffing.
F 0600: The facility failed to protect residents from abuse and neglect, including refusal of care and verbal abuse by staff toward Residents 16 and 20, resulting in immediate jeopardy that was later removed.
F 0658: The facility failed to follow physician orders for medications for Residents 305, 20, and 224, including missed insulin doses, failure to notify physicians, and missed or delayed administration of multiple medications.
F 0692: The facility failed to provide adequate fluids such as ice water and other beverages to residents, including Resident 13 and others, and failed to complete nutritional assessments as required.
F 0725: The facility failed to provide adequate nursing staffing to meet resident needs, resulting in missed medications, delayed call light responses, unmet care needs, and resident complaints about agency staff and weekend staffing.
F 0804: The facility failed to ensure condiments were offered and served with meals for residents including R174, R13, and R41, impacting meal palatability and resident satisfaction.
Report Facts
Facility census: 82
BIMS score: 14
BIMS score: 11
BIMS score: 15
BIMS score: 15
BIMS score: 10
BIMS score: 15
BIMS score: 15
Bariatric briefs delivered: 15
Briefs per resident per day: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA7 | Certified Nurse Aide | Named in abuse and neglect findings for refusal to assist Resident 16 and Resident 20 |
| LPN1 | Licensed Practical Nurse | Received neglect report from Resident 16 and assisted resident after neglect incident |
| RN2 | Registered Nurse | Oncoming nurse who refused to administer missed medications on 04/08/24 evening shift |
| CMT2 | Certified Medication Technician | Agency staff who failed to administer medications properly on 04/08/24 evening shift |
| LPN3 | Licensed Practical Nurse | Reported usual staffing and shortages due to no shows |
| CNA5 | Certified Nurse Aide | Agency staff who turned off Resident 13's call light without providing care |
| CNA2 | Certified Nurse Assistant | Reported filling Resident 13's water pitcher and acknowledged fluid availability issues |
| LPN4 | Licensed Practical Nurse | Reported monitoring hydration and staff passing ice water |
| RN J | Agency Registered Nurse | Documented blood glucose and medication administration issues for Resident 305 |
| LPN A | Licensed Practical Nurse | Documented insulin administration and blood glucose monitoring for Resident 305 |
| Administrator | Facility Administrator | Reported staffing improvements and awareness of resident concerns |
| Director of Nursing | Director of Nursing | Reported staffing expectations and medication administration policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported on staffing, medication administration failures, and agency staff issues |
| Dietary Manager | Dietary Manager | Reported condiments should be offered to residents per diet |
| Registered Dietitian | Registered Dietitian | Reported lack of nutritional assessments and beverage availability concerns |
Inspection Report
Life Safety
Census: 83
Capacity: 96
Deficiencies: 2
Date: Apr 12, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services on 04/12/24 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with requirements related to smoke detector sensitivity testing and sprinkler system maintenance and testing. Deficiencies included failure to perform smoke detector sensitivity testing every alternate year and failure to conduct required quarterly inspections and testing of the sprinkler system components.
Deficiencies (2)
K345: The facility failed to ensure smoke detection sensitivity testing of smoke detectors was completed every alternate year as required by NFPA 72. This deficiency had the potential to affect all 83 residents.
K353: The facility failed to ensure the sprinkler system's control valves, water flow alarms, tamper switches, and supervisory signals were inspected and tested quarterly. The sprinkler system was only inspected annually, lacking required quarterly and semiannual testing.
Report Facts
Occupied beds: 83
Total beds: 96
Inspection Report
Census: 82
Deficiencies: 24
Date: Apr 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care, safety, staffing, infection control, and medication management.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, failure to provide written notice for room changes, failure to ensure residents' rights to make decisions, inadequate staffing leading to missed medications and delayed call light responses, failure to provide adequate activities and hydration, medication errors, improper catheter care, and failure to maintain infection control standards.
Deficiencies (24)
F 0550: The facility failed to ensure residents received services in a manner that promoted dignity and quality of life, including grooming and respectful feeding assistance.
F 0551: The facility failed to give residents' representatives the ability to exercise residents' rights, including improper handling of resident's mail and communication devices.
F 0553: The facility failed to invite two cognitively intact residents to participate in their care plan meetings as requested.
F 0558: The facility failed to provide bariatric incontinent briefs in ample supply to meet the needs of three residents.
F 0559: The facility failed to provide written notice prior to a facility-initiated room change for one resident.
F 0565: The facility failed to address and resolve grievances raised by the resident council, including concerns about call lights, staff behavior, and food quality.
F 0578: The facility failed to ensure residents and/or their representatives received written information about and assistance with formulating advance directives for three residents.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment; resident rooms and living spaces were unclean and in poor repair with strong odors and debris.
F 0585: The facility failed to complete an investigation for one resident's grievance and failed to inform the resident of the outcome.
F 0600: Immediate Jeopardy - The facility failed to ensure two residents were free from abuse and neglect, including refusal of care and call light abuse by staff. The Immediate Jeopardy was removed on 04/11/24.
F 0609: Immediate Jeopardy - The facility failed to timely report allegations of neglect to supervisors and the Abuse Coordinator for two residents. The Immediate Jeopardy was removed on 04/11/24.
F 0658: The facility failed to follow physician orders for three residents, including missed insulin doses and failure to notify physicians of high blood glucose levels.
F 0677: The facility failed to provide activities of daily living care for one resident who was totally dependent on staff.
F 0679: The facility failed to provide sufficient activities and documentation for multiple residents; the Activity Director was not qualified.
F 0689: The facility failed to ensure a resident who smoked wore a smoking apron for safety and failed to care plan for refusals.
F 0690: The facility failed to maintain oxygen therapy equipment properly, including undated tubing and humidifier bottles and dirty concentrator filters.
F 0695: The facility failed to ensure allegations of neglect were reported timely to supervisors and the Abuse Coordinator for two residents.
F 0725: The facility failed to ensure adequate nursing staffing to meet residents' needs, resulting in missed medications, delayed call light responses, and unmet care needs.
F 0745: The facility failed to provide medically-related social services to ensure residents maintained their highest practicable wellbeing, including failure to provide room change notice, respect resident decisions, and invite residents to care plan meetings.
F 0755: The facility failed to provide medications as ordered by the physician for two residents, including missed doses and failure to notify physicians.
F 0761: The facility failed to ensure medication carts and treatment carts were locked and secured, and failed to maintain medication refrigerator temperature logs.
F 0804: The facility failed to ensure condiments were offered and served with food for three residents.
F 0882: The facility failed to ensure the Infection Prevention and Control Program was overseen by an Infection Preventionist who had completed specialized training.
F 0919: The facility failed to maintain a working wireless call light system, resulting in extensive call light response delays and lack of pagers for staff.
Report Facts
Facility census: 82
Medication error rate: 8
Missed doses of hydrocodone/acetaminophen: 6
Call light response times: 87
BIMS scores: 15
BIMS scores: 10
BIMS scores: 6
BIMS scores: 11
BIMS scores: 14
BIMS scores: 9
BIMS scores: 4
BIMS scores: 12
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | CNA | Named in failure to provide fluids and call light response |
| Certified Nurse Aide 3 | CNA | Named in call light response failure and activity assistance |
| Certified Nurse Aide 6 | CNA | Named in failure to provide condiments and shower assistance |
| Certified Medication Technician 1 | CMT | Named in medication errors and missed medication |
| Certified Medication Technician 2 | CMT | Named in medication errors and missed medication |
| Licensed Practical Nurse 1 | LPN | Named in neglect allegation and medication administration |
| Licensed Practical Nurse 3 | LPN | Named in medication cart left unlocked |
| Licensed Practical Nurse 4 | LPN | Named in medication cart left unlocked and neglect allegation |
| Licensed Practical Nurse 7 | LPN | Named in catheter care observation |
| Registered Nurse 2 | RN | Named in medication administration and neglect allegation |
| Registered Nurse J | RN | Named in medication administration and documentation |
| Social Service Director | SSD | Named in resident rights and grievance failures |
| Director of Nursing | DON | Named in multiple findings including infection control and staffing |
| Assistant Director of Nursing | ADON | Named in multiple findings including neglect and staffing |
| Activity Director | AD | Named in activity program deficiencies |
| Central Supply Clerk | CS | Named in incontinent brief supply issues and oxygen supply |
| Administrator | Administrator | Named in multiple findings including staffing and grievance response |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Date: Nov 15, 2023
Visit Reason
Investigation of medication administration concerns and behavioral issues following complaints about missed medications and resident-to-resident intimidation.
Complaint Details
The investigation was triggered by concerns that medications were not administered over the weekend of 11/4/23 and 11/5/23 by new contract staff, resulting in missed doses for 17 of 33 residents assigned to the staff. Additionally, Resident #1 exhibited threatening and bullying behaviors toward other residents, causing fear and distress.
Findings
The facility failed to administer medications as ordered and in a timely manner for multiple residents, with documentation discrepancies and lack of staff training. Additionally, the facility failed to provide appropriate treatment and interventions for a resident with severe mental illness who exhibited bullying and threatening behaviors toward other residents.
Deficiencies (2)
F0658: Facility staff failed to administer medications as ordered and timely for 14 of 23 sampled residents, including failure to document narcotic administration and assess pain levels. Staff lacked training and resources such as laptop chargers, impacting medication administration.
F0742: Facility failed to provide appropriate treatment and services for Resident #1 with severe mental illness, who exhibited bullying, intimidation, and threatening behaviors. Staff did not develop adequate interventions or psychiatric follow-up, resulting in actual harm to other residents.
Report Facts
Residents affected by medication issues: 14
Residents assigned to CMT A: 33
Residents with missed medication doses: 17
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication administration failures and lack of training |
| Director of Nursing | Director of Nursing (DON) | Provided investigation summary and interview statements regarding medication and behavioral issues |
| Certified Nurse Aide K | Certified Nurse Aide | Reported on Resident #1's bullying and intimidating behaviors |
| Certified Medication Technician C | Certified Medication Technician | Reported medication administration concerns and described Resident #1's behaviors |
| Social Service Designee | Social Service Designee | Described Resident #1's behaviors and attempts to redirect |
| Administrator | Facility Administrator | Provided statements on medication administration and resident behavioral appropriateness |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 2
Date: Nov 15, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for St Peters Manor Care Center following a survey completed on 11/15/2023. It addresses deficiencies found related to medication administration and treatment/services for mental/psychosocial concerns.
Findings
The facility failed to meet professional standards in medication administration, including timely and accurate documentation and administration of narcotics and other medications. Additionally, the facility failed to ensure appropriate treatment and services for residents with mental health diagnoses, including behavioral health interventions and staff training.
Deficiencies (2)
F658: The facility failed to follow professional standards in medication administration for 14 of 23 sampled residents, including failure to administer medications timely, document narcotic administration, and ensure staff awareness of medication concerns. The facility census was 80.
F742: The facility failed to ensure appropriate treatment and services for a resident with bipolar disorder, including failure to provide behavioral health services and staff training. The facility census was 80.
Report Facts
Residents sampled: 23
Residents affected: 14
Facility census: 80
Residents with mental health diagnosis: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician C | Certified Medication Technician | Alerted Director of Nursing about medication concerns and provided interview statements |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration issues and staffing |
| Assistant Director of Nurses | Assistant Director of Nurses | Reviewed narcotic books and medication records |
| Certified Nurse Aide K | Certified Nurse Aide | Provided interview statements about resident behaviors |
| Certified Medication Technician A | Certified Medication Technician | Documented medication administration and provided interview statements |
Inspection Report
Routine
Census: 86
Deficiencies: 6
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, staffing, infection control, and food service.
Findings
The facility failed to provide reasonable accommodations for residents' needs, maintain updated care plans, provide adequate assistance with activities of daily living, ensure sufficient nursing staff, serve food at safe temperatures, and implement effective infection prevention and control measures during a COVID-19 outbreak.
Deficiencies (6)
F 0558: The facility failed to reasonably accommodate the needs and preferences of four residents, including failure to identify needs of visually impaired residents and failure to provide water routinely.
F 0657: The facility failed to update care plans consistent with resident specific conditions, needs, and risks for three residents, including failure to reflect significant changes in status.
F 0677: The facility failed to provide necessary care and assistance for activities of daily living for five residents, resulting in poor personal hygiene and body odor.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed response to call lights and inadequate personal care for four residents.
F 0804: The facility failed to ensure food was served at a safe, appetizing temperature and did not reheat or replace cold food for residents.
F 0880: The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, including inadequate resident and staff testing, improper use of PPE, failure to wash hands, and improper disposal of contaminated waste.
Report Facts
Facility census: 86
Residents affected: 4
Residents affected: 3
Residents affected: 5
Residents affected: 4
Residents affected: 5
Residents affected: 16
Residents positive for COVID-19: 40
Inspection Report
Routine
Census: 86
Deficiencies: 9
Date: Sep 12, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident care, staffing, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, incomplete care plans, medication administration errors, inadequate restorative nursing services, insufficient personal care and hygiene assistance, inadequate staffing levels, improper food temperature management, and lapses in infection prevention and control practices during a COVID-19 outbreak.
Deficiencies (9)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents, including failure to identify needs of visually impaired residents and failure to routinely provide water.
F 0657: The facility failed to update care plans consistent with resident specific conditions, needs, and risks for three residents.
F 0658: The facility failed to follow professional standards for medication administration, including administering incorrect medications and failing to administer prescribed controlled substances.
F 0676: The facility failed to establish restorative nursing programs with specific goals and failed to provide restorative nursing therapy as needed for three residents.
F 0677: The facility failed to provide necessary care and services to maintain personal hygiene and prevent body odor for five residents unable to complete their own activities of daily living.
F 0725: The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in family members assisting with personal care and meal tray passing, and delays in answering call lights.
F 0726: The facility failed to ensure nursing assistants demonstrated competency in skills and techniques necessary to care for residents, including transfers, charting, infection control, and personal care.
F 0804: The facility failed to ensure food was served at a safe, appetizing temperature, with multiple residents receiving cold meals and no reheating offered.
F 0880: The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, including failure to complete resident and staff testing timely, improper use of PPE, and improper disposal of contaminated waste.
Report Facts
Facility census: 86
Residents affected by COVID-19 outbreak: 40
Residents tested positive on 10/5/23: 6
Residents tested positive on 10/7/23: 11
Residents tested positive on 10/9/23: 6
Residents tested positive on 10/10/23: 10
Residents tested positive on 10/11/23: 4
Residents tested positive on 10/13/23: 1
Residents tested positive on 10/14/23: 1
Residents tested positive on 10/15/23: 1
Residents tested positive on 10/17/23: 0
Staffing ratio day shift: 1
Staffing ratio evening shift: 1
Staffing ratio night shift: 1
Restorative nurse program residents: 14
Showers for Resident #6 in October 2023: 1
Showers for Resident #3 in 33 days: 3
Showers for Resident #4 in 33 days: 3
Showers for Resident #18 in 7 days: 2
Showers for Resident #2 on 9/9/23 and 9/10/23: 0
Meals served cold temperature: 5
Temperature of mashed potatoes: 92
Temperature of baked beans: 90
Temperature of barbequed brisket: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA D | Certified Nurse Aide | Responsible for restorative nursing program, worked floor due to staffing shortages |
| LPN C | Licensed Practical Nurse | Involved in medication administration errors and resident care |
| CNA M | Certified Nurse Assistant | Assisted resident with cold food, unaware of reheating policy |
| NA A | Nursing Assistant | Failed to use proper PPE when delivering meals to COVID positive residents |
| DON | Director of Nursing | Provided statements on staffing, infection control, and care expectations |
| ADON | Assistant Director of Nursing | Infection Preventionist, provided statements on COVID-19 outbreak management and staff hygiene |
| CMT E | Certified Medication Technician | Occasionally assisted with restorative nursing program |
| NA H | Nursing Assistant | Demonstrated improper hygiene and care techniques |
| RN H | Registered Nurse | Involved in wound care and resident transfers |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 5
Date: Jun 1, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for St Peters Manor Care Center.
Findings
The facility was found deficient in providing reasonable accommodations for resident needs and preferences, infection prevention and control, and immunization policies. Specific residents lacked access to call lights and proper infection control practices were not consistently followed.
Deficiencies (5)
F558 Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3) The facility failed to provide reasonable accommodation of resident needs and preferences, evidenced by residents not having access to call lights and delayed staff response.
F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) The facility failed to ensure staff changed gloves and washed hands as indicated and did not properly utilize infection control supplies for respiratory care.
F883 Influenza and Pneumococcal Immunizations CFR(s): 483.80(d)(1)(2) The facility failed to ensure residents were offered and received influenza and pneumococcal vaccinations according to CDC guidelines.
A4075 Nursing Care per Resident Condition The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4086 Infection Control/Communicable Disease The facility failed to use acceptable infection control procedures and timely report communicable diseases as required by state regulations.
Report Facts
Facility census: 70
Sampled residents: 19
Completion date for corrective actions: Jun 28, 2023
Inspection Report
Routine
Census: 70
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
Routine inspection to assess infection prevention and control practices and vaccination policies at the facility.
Findings
The facility failed to ensure proper infection control practices including hand hygiene and glove changes during resident care for multiple residents. Additionally, the facility did not offer pneumococcal vaccinations to eligible residents according to CDC guidelines.
Deficiencies (2)
F 0880: The facility failed to ensure staff changed gloves and washed hands as indicated during care for residents #2, #3, and #7. Oxygen tubing was found uncovered on the floor or bed for residents #7 and #18.
F 0883: The facility failed to offer pneumococcal vaccination to eligible residents #3, #7, and #9 as per CDC guidelines, resulting in residents not being up-to-date on pneumonia vaccinations.
Report Facts
Residents affected: 3
Residents affected: 3
Facility census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Named in infection control deficiency related to glove and hand hygiene practices | |
| Nurse Aide (NA) I | Named in infection control deficiency related to glove and hand hygiene practices | |
| Director of Nursing (DON) | Interviewed regarding expectations for hand hygiene and vaccination compliance | |
| Infection Preventionist (IP) | Responsible for vaccination audits and compliance | |
| Administrator | Interviewed regarding awareness of vaccination status |
Inspection Report
Routine
Census: 70
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including call light accessibility and infection prevention and control practices.
Findings
The facility failed to ensure residents had access to call lights, resulting in delayed staff response and discomfort for residents. Additionally, staff did not consistently follow infection control protocols such as changing gloves and washing hands during care, and oxygen tubing was improperly stored.
Deficiencies (2)
F 0558: The facility failed to reasonably accommodate the needs of residents by not ensuring call lights were accessible, causing residents to yell for help and experience delayed responses.
F 0880: The facility failed to implement proper infection prevention and control, including failure to change gloves and wash hands during care and improper handling of respiratory care supplies.
Report Facts
Facility census: 70
Residents sampled: 19
Residents affected by call light deficiency: 2
Residents affected by infection control deficiency: 3
Residents affected by respiratory care deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Named in infection control deficiency for not changing gloves or washing hands properly during care | |
| Nurse Aide (NA) I | Named in infection control deficiency for improper glove use and hand hygiene during care | |
| Director of Nursing (DON) | Provided statements on expected hand hygiene and oxygen tubing storage practices | |
| Administrator | Stated call lights should be accessible to residents at all times |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 13
Date: May 16, 2023
Visit Reason
The inspection was the annual survey of St Peters Manor Care Center to assess compliance with federal regulations and investigate allegations of abuse and neglect.
Findings
The facility was found deficient in multiple areas including resident rights, abuse and neglect reporting, use of restraints, nursing care, and fall risk management. Several residents experienced delayed responses to call lights and incidents of misappropriation of resident property were noted.
Deficiencies (13)
F550 Resident Rights: The facility failed to ensure timely response to call lights for two residents, resulting in prolonged soiling and skin irritation. Staff did not consistently follow the facility's call light policy.
F604 Right to be Free from Physical Restraints: The facility failed to accurately assess and document the use of a pommel cushion restraint for one resident. The resident was unable to easily get out of the wheelchair.
F609 Reporting of Alleged Violations: The facility failed to report allegations of misappropriation of resident property for two residents to the state agency in a timely manner. Investigations and corrective actions were incomplete.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of misappropriation of money by two residents and did not complete required corrective actions.
F658 Services Provided Meet Professional Standards: The facility failed to administer insulin and check blood glucose levels as ordered for one resident and failed to ensure hearing aids were routinely placed for another resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to consistently implement fall prevention interventions. One resident sustained a head laceration from a fall. Post-fall evaluations were incomplete.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure one resident received adequate nutritional intake and weekly weights were not consistently obtained for another resident at risk for weight loss.
F744 Treatment/Service for Dementia: The facility failed to consistently follow care plans for residents with dementia, including monitoring wandering behaviors and providing appropriate supervision and redirection.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions and acceptable nursing practice.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor: The facility failed to provide adequate diet and nutrition assessment in accordance with physician orders and National Research Council recommendations.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and failed to report incidents as required.
A8026 Restraints-Medical Symptom Must Be Authorized: The facility failed to ensure physical or chemical restraints were authorized in writing by a physician for a specified period of time.
A8030 Dignity/Privacy: The facility failed to treat residents with full recognition of dignity and privacy, including privacy during treatment and care.
Report Facts
Facility census: 72
Facility census: 73
Deficiencies cited: 12
Corrective action completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Sloe | Administrator | Signed the report and plan of correction |
| Amanda Clark | Surveyor | Named in relation to professional standards deficiency |
| Director of Nursing | Mentioned in interviews and corrective action plans | |
| Assistant Director of Nursing | Mentioned in interviews regarding restraint assessment | |
| Registered Nurse Q | Registered Nurse | Interviewed regarding hospital discharge and resident care |
| Licensed Practical Nurse P | Licensed Practical Nurse | Interviewed regarding hearing aids and resident care |
| Certified Nurse Assistant M | Certified Nurse Assistant | Observed resident care and interviewed |
| Certified Nurse Assistant J | Certified Nurse Assistant | Interviewed regarding resident care |
| Restorative Aide K | Restorative Aide | Interviewed regarding resident behavior and care |
Inspection Report
Routine
Census: 73
Deficiencies: 8
Date: May 16, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to respond timely to residents' call lights causing distress and skin issues, improper use and assessment of physical restraints, failure to report and investigate allegations of misappropriation of resident property, failure to administer insulin and monitor blood glucose as ordered, failure to provide hearing aids consistently, inadequate fall prevention and post-fall evaluations, failure to provide adequate nutritional support and assistance, and failure to implement care plan interventions for residents with dementia and wandering behaviors.
Deficiencies (8)
F 0550: The facility failed to ensure timely response to call lights for two residents, resulting in residents lying in soiled briefs causing skin irritation and emotional distress.
F 0604: The facility failed to accurately assess and document the use of a pommel cushion as a restraint for one resident, and failed to complete required pre-restraint assessments.
F 0609: The facility failed to timely report allegations of misappropriation of property for two residents and did not complete required investigations.
F 0610: The facility failed to thoroughly investigate allegations of misappropriation of property for two residents, leaving investigations incomplete.
F 0658: The facility failed to administer insulin and monitor blood glucose levels as ordered for one resident with diabetes, resulting in a hospital readmission for diabetic ketoacidosis. The facility also failed to ensure hearing aids were routinely placed for one resident with hearing impairment.
F 0689: The facility failed to consistently implement, evaluate, and modify fall prevention interventions for one resident with multiple falls, and failed to complete thorough post-fall evaluations and notifications.
F 0692: The facility failed to ensure one resident received nutritional orders including health shakes and therapeutic cups, failed to provide appropriate feeding assistance, and failed to obtain weekly weights as directed.
F 0744: The facility failed to consistently follow the care plan for one resident with dementia related to wandering and intrusive behaviors, resulting in the resident wandering into other residents' rooms, taking food, and causing distress to other residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 73
Weight loss: 5.6
Fall risk score: 19
Laceration size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN O | Licensed Practical Nurse | Named in failure to clarify insulin and blood glucose orders |
| RN Q | Registered Nurse | Named in failure to monitor blood glucose and respond to high blood sugar |
| LPN P | Licensed Practical Nurse | Named in hearing aid availability and documentation issues |
| CNA K | Certified Nurse Aide | Named in wandering resident redirection and supervision |
| RA K | Restorative Aide | Named in wandering resident supervision and diversion activities |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding falls, wandering, and care plan adherence |
| Administrator | Facility Administrator | Named in interviews regarding overall facility deficiencies and corrective expectations |
| Social Service Director | Social Service Director | Named in misappropriation reporting and hearing aid management |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from sexual abuse, failure to assist a resident with hearing aids, and failure to prevent falls for a high-risk resident.
Complaint Details
The complaint investigation substantiated that Resident #1 sexually abused Resident #2 and made unwelcome advances toward Resident #3. The facility failed to protect residents despite prior knowledge of Resident #1's behaviors. Additionally, the facility failed to assist Resident #7 with hearing aids and failed to prevent a fall for Resident #7, a known fall risk.
Findings
The facility failed to protect one resident from sexual abuse by another resident, failed to assist a resident in maintaining hearing aids and proper communication, and failed to provide adequate supervision to prevent a fall for a high-risk resident. Multiple interviews, observations, and record reviews confirmed these deficiencies.
Deficiencies (3)
F 0600: The facility failed to protect one resident from sexual abuse by another resident despite prior knowledge of inappropriate sexual behaviors. Staff did not adequately monitor or intervene to prevent repeated incidents.
F 0685: The facility failed to assist one resident in maintaining hearing aids and ensuring hearing aids were in place daily, impairing communication and care.
F 0689: The facility failed to provide adequate supervision and fall prevention interventions for one high-risk resident, resulting in a preventable fall with injury.
Report Facts
Facility census: 68
Fall risk assessment score: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Reported and documented fall incident and resident supervision issues |
| CNA D | Certified Nurse Aide | Observed and reported sexual abuse incident involving Resident #1 and Resident #2 |
| NP E | Nurse Practitioner | Witnessed sexual abuse incident and intervened |
| CNA C | Certified Nurse Aide | Assigned to Resident #1's hall but was not informed of monitoring needs |
| Social Services Director | Provided information on Resident #1's prior behaviors and hearing aid issues | |
| Assistant Director of Nursing | Provided information on Resident #1's behaviors and fall prevention policies | |
| Administrator | Provided statements regarding facility policies and awareness of incidents |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 6
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse and neglect at St Peters Manor Care Center.
Complaint Details
The complaint investigation substantiated that Resident #2 was sexually abused by Resident #1. The facility failed to protect the resident and did not properly monitor or intervene despite knowledge of prior incidents. The investigation included interviews, record reviews, and observations confirming the abuse and inadequate oversight.
Findings
The facility failed to protect one resident from sexual abuse by another resident and did not provide proper treatment and supervision related to hearing and fall prevention. Multiple deficiencies were cited related to abuse prevention, hearing/vision treatment, and accident hazards.
Deficiencies (6)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect one resident from sexual abuse by another resident and did not meet requirements to prevent verbal, mental, sexual, or physical abuse.
F685 Treatment/Devices to Maintain Hearing/Vision: The facility failed to assist one resident to receive proper treatment and assistive devices to maintain hearing and hearing abilities.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide protective oversight and supervision to prevent accidents, resulting in a fall for one resident.
A4074 Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A8023 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents.
Report Facts
Facility census: 68
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Keen | Surveyor | Named in the sexual abuse finding |
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 2
Date: Nov 17, 2022
Visit Reason
The inspection was conducted to assess compliance with care requirements for dependent residents, specifically focusing on activities of daily living such as bathing and grooming.
Findings
The facility failed to ensure five residents received necessary assistance with bathing and grooming, with documentation showing multiple refusals and missed showers. The care plans did not address residents' bathing needs adequately, and staff failed to provide consistent shower assistance.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure five residents received necessary assistance with activities of daily living, including bathing and grooming. Documentation showed multiple refusals and missed showers without proper follow-up.
A4076 Clean, Dry, Odor Free: Each resident shall be clean, dry, and free of offensive body and mouth odor. This regulation was not met as referenced by F677.
Report Facts
Facility census: 74
Number of residents assessed: 5
Plan of correction completion date: Dec 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Gee | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Census: 71
Deficiencies: 24
Date: Apr 3, 2022
Visit Reason
Routine state inspection to assess compliance with healthcare regulations including resident care, safety, staffing, and infection control.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, inadequate response to resident council concerns, improper management of resident funds, unsafe and unclean environment, failure to provide timely bed hold notices, incomplete and outdated care plans, insufficient assistance with activities of daily living, inadequate CPR certified staff coverage, medication management issues, food served at unsafe temperatures, insufficient staffing levels, delayed call light responses, and failure to ensure COVID-19 precautions for unvaccinated staff.
Deficiencies (24)
F 0550: Facility failed to ensure residents were treated with dignity and respect, including improper meal service in Styrofoam containers and disrespectful staff interactions.
F 0565: Facility failed to respond adequately to resident council concerns and provide feedback to residents.
F 0567: Facility failed to deposit residents' personal funds over $50 into interest bearing accounts and credit interest earned for two residents.
F 0584: Facility failed to maintain a safe, clean, and comfortable environment with multiple maintenance issues in resident rooms and common areas.
F 0625: Facility failed to provide written notice of bed hold policies to residents or representatives upon hospital transfer for two residents.
F 0656: Facility failed to develop and implement comprehensive, updated care plans reflecting residents' current needs for four residents.
F 0657: Facility failed to update care plans timely to reflect changes in resident condition and care needs for three residents.
F 0677: Facility failed to provide adequate assistance with activities of daily living including bathing and hygiene for three residents.
F 0678: Facility failed to ensure adequate CPR certified staff coverage on all shifts and failed to maintain accurate resident code status documentation for four residents.
F 0684: Facility failed to provide food at safe and appetizing temperatures and failed to maintain kitchen cleanliness.
F 0686: Facility failed to implement interventions to prevent and treat pressure ulcers, maintain air mattress settings, reposition residents timely, and provide restorative nursing services as ordered for multiple residents.
F 0688: Facility failed to provide restorative nursing services as ordered for three residents due to staffing shortages.
F 0689: Facility failed to ensure safe resident transfers using gait belts and adequate staff assistance for two residents.
F 0725: Facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses, missed showers, and inadequate care.
F 0755: Facility failed to ensure RN coverage for eight hours daily as required by regulation.
F 0761: Facility failed to ensure accountability and secure storage of controlled medications and failed to remove expired medications.
F 0804: Facility failed to ensure meals were served at safe and appetizing temperatures and maintain kitchen cleanliness.
F 0809: Facility failed to provide bedtime snacks to residents as requested or per policy.
F 0812: Facility failed to maintain clean kitchen environment including freezers, refrigerators, dishwasher, and floors.
F 0880: Facility failed to implement infection control practices including hand hygiene, glove use, and proper use of N95 masks by unvaccinated staff; failed to prevent contamination of oxygen delivery equipment.
F 0883: Facility failed to ensure pneumococcal vaccinations were provided or documented for five residents as per CDC guidelines.
F 0888: Facility failed to ensure unvaccinated staff wore N95 masks and completed required COVID-19 testing twice weekly.
F 0909: Facility failed to regularly inspect bed frames, mattresses, and assist bars for safety and entrapment risks for three residents.
F 0919: Facility failed to maintain a functional wireless call light system and ensure staff carried pagers to respond timely to resident calls.
Report Facts
Residents affected by dignity deficiency: 10
Residents affected by resident council deficiency: 5
Residents affected by personal funds deficiency: 2
Residents affected by environment deficiency: 71
Residents affected by bed hold notice deficiency: 2
Residents affected by care plan deficiency: 4
Residents affected by bathing deficiency: 3
Residents affected by CPR deficiency: 4
Residents affected by food temperature deficiency: 5
Residents affected by pressure ulcer deficiency: 4
Residents affected by restorative nursing deficiency: 3
Residents affected by transfer technique deficiency: 2
Residents affected by call light response deficiency: 7
Residents affected by medication management deficiency: 1
Residents affected by medication storage deficiency: 1
Residents affected by medication self-administration deficiency: 1
Residents affected by expired medication deficiency: 1
Residents affected by infection control deficiency: 3
Residents affected by pneumococcal vaccination deficiency: 5
Residents affected by RN coverage deficiency: 71
Residents affected by staffing deficiency: 11
Residents affected by snack provision deficiency: 5
Residents affected by kitchen cleanliness deficiency: 71
Residents affected by bed safety inspection deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN PP | Licensed Practical Nurse | Left shift early on 3/31/22 leaving no licensed nurse on night shift |
| DON | Director of Nursing | Named in medication storage and staffing deficiencies |
| LPN D | Licensed Practical Nurse | Named in medication cart management and wound care |
| CMT AA | Certified Medication Technician | Named in medication cart management and eye drop administration |
| NA M | Nurse Aide | Unvaccinated staff not wearing N95 mask as required |
| NA O | Nurse Aide | Unvaccinated staff not wearing N95 mask as required |
| CMT SS | Certified Medication Technician | Named in narcotic count documentation |
| CNA X | Certified Nurse Aide | Named in improper glove use and resident care |
| CMT AA | Certified Medication Technician | Named in medication cart management |
| LPN G | Licensed Practical Nurse | Named in medication administration and snack provision |
| NA LL | Nurse Aide | Named in improper transfer technique |
| CNA II | Certified Nurse Aide | Named in improper transfer technique |
| CNA B | Certified Nurse Aide | Named in improper transfer technique |
| CNA X | Certified Nurse Aide | Named in improper incontinence care |
| CMT AA | Certified Medication Technician | Named in eye drop administration without hand hygiene |
| NA P | Nurse Aide | Named in call light monitoring |
| NA U | Nurse Aide | Named in call light monitoring |
| NA HH | Certified Nurse Assistant | Named in staffing shortage on 3/31/22 night shift |
| LPN PP | Licensed Practical Nurse | Named in staffing shortage on 3/31/22 night shift |
| LPN QQ | Licensed Practical Nurse | Named in staffing shortage on 4/1/22 day shift |
| ADON | Assistant Director of Nursing | Named in staffing and COVID-19 testing deficiencies |
| NA M | Nurse Aide | Named in COVID-19 mask noncompliance |
| NA O | Nurse Aide | Named in COVID-19 mask noncompliance |
| Employee H | Unvaccinated staff wearing surgical mask instead of N95 | |
| Employee I | Unvaccinated staff wearing surgical mask instead of N95 | |
| Employee J | Unvaccinated staff wearing surgical mask instead of N95 | |
| Employee K | Unvaccinated staff not tested as documented | |
| Employee L | Unvaccinated staff not tested as documented | |
| Employee M | Unvaccinated staff not tested as documented |
Inspection Report
Routine
Census: 92
Deficiencies: 14
Date: Sep 6, 2019
Visit Reason
Routine inspection of St Peters Rehab and Healthcare Center to assess compliance with Medicare/Medicaid regulations including resident care, infection control, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare non-coverage notices, failure to maintain resident dignity and privacy during care, failure to follow physician orders, inadequate assistance with activities of daily living, insufficient fall prevention interventions, improper catheter care, improper feeding tube management, dietary service deficiencies including incorrect portion sizes and food preparation, failure to accommodate resident food preferences, inadequate hydration assistance, improper infection control practices including hand hygiene and glove use, and improper waste management.
Deficiencies (14)
F 0582: Facility failed to provide Notice of Medicare Provider Non-Coverage to residents discharged from Medicare services timely as required by policy.
F 0583: Facility failed to maintain resident dignity and privacy during personal care for multiple residents, exposing them to roommates and others.
F 0658: Facility failed to follow physician orders for one resident, including failure to apply pressure relieving devices as ordered.
F 0677: Facility failed to provide adequate assistance with activities of daily living including hygiene, oral care, and incontinence care for multiple residents.
F 0689: Facility failed to implement adequate fall prevention interventions and failed to update care plans after resident falls.
F 0690: Facility failed to provide appropriate catheter care and maintain urinary catheter drainage bags below bladder level to prevent urinary tract infections.
F 0693: Facility failed to ensure feeding tube care was provided according to policy and failed to maintain resident head elevation during tube feeding to prevent aspiration.
F 0803: Facility failed to ensure dietary staff served correct portion sizes and prepared food according to recipes for pureed and mechanical soft diets.
F 0804: Facility failed to ensure residents on mechanical soft and pureed diets received food with proper texture consistent with diet orders.
F 0805: Facility failed to accommodate resident food preferences and failed to provide food choices to residents on pureed and mechanical soft diets.
F 0807: Facility failed to ensure residents had adequate fluids available and failed to offer fluids during meals to a resident.
F 0812: Facility failed to ensure proper handwashing and glove use by dietary staff and failed to keep kitchen trash cans covered when not in use.
F 0814: Facility failed to keep outdoor garbage dumpster closed to prevent access to rodents and pests.
F 0880: Facility failed to ensure nursing staff washed hands and changed gloves appropriately during resident care, resulting in contamination risks for multiple residents.
Report Facts
Facility census: 92
Residents on pureed diet: 8
Residents on mechanical soft diet: 21
Resident #87 last Medicare covered day: Mar 18, 2019
Resident #85 last Medicare covered day: Mar 15, 2019
Resident #87 SNFABN and NOMNC signed: 2019-03-26, 8 days after Medicare services ended
Resident #85 SNFABN and NOMNC missing: No evidence of provision
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