Deficiencies (last 6 years)
Deficiencies (over 6 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
73% occupied
Based on a October 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 74
Capacity: 102
Deficiencies: 5
Date: Oct 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving a resident's death and concerns about facility practices including fire alarm system maintenance, wastebasket compliance, business licensing, nursing care, and infection control.
Complaint Details
The complaint investigation was triggered by an incident where a resident (#22) with advanced dementia was not properly monitored during the night shift, leading to the resident being found deceased without CPR initiated. The allegation was substantiated and the violation was determined to be at an imminent danger Class I level initially, later lowered to Class II after corrective actions.
Findings
The facility was found deficient in maintaining the fire alarm system, using approved wastebaskets, obtaining required business licenses, monitoring a resident with dementia leading to a fatality, and posting infection control alerts. The facility had a census of 74 residents and a licensed capacity of 102 beds at the time of survey.
Deficiencies (5)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain. The facility failed to ensure only authorized personnel could access, silence, and reset the main fire alarm panel, leaving it unlocked and accessible.
19 CSR 30-85.022(40)(A) Wastebaskets, Metal/UL/FM. The facility failed to ensure all trash cans were metal or UL/FM approved, with several plastic trash cans observed without proper ratings.
19 CSR 30-85.032(48)(A) Additional Businesses-Requires DHSS Approval. The facility failed to obtain an active second business license for a salon operating on site, with the previous license expired.
19 CSR 30-85.042(66) Nursing Care Per Resident Condition. The facility failed to monitor a resident with advanced dementia and cognitive impairment, resulting in the resident being found deceased without timely CPR initiation.
19 CSR 30-85.042(77) Infection Control/Communicable Disease. The facility failed to post visual alerts for transmission-based precautions for residents with COVID-19 and did not fully implement infection control procedures.
Report Facts
Census: 74
Total Capacity: 102
Deficiency counts: 5
Residents testing positive for COVID-19: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Barron | Senior Executive Director | Named in relation to facility oversight and plan of correction |
| CM A | Care Manager involved in resident monitoring and investigation of resident #22 death | |
| CMT B | Certified Medication Technician | Involved in resident #22 incident and emergency response |
| Lead Care Manager L | Interviewed regarding resident monitoring policies | |
| Executive Director (ED) | Provided statements about business licensing and facility operations | |
| Maintenance Director | Interviewed about fire alarm panel security and maintenance | |
| Activity Director | Responsible for posting visual alerts/signs for infection control |
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with medication distribution, administration, control, and use regulations at Sunrise of Des Peres. The document includes a statement of deficiencies and a plan of correction related to medication management.
Findings
The facility failed to ensure a safe and effective medication system as staff did not administer or document medications for six out of nine sampled residents. Documentation gaps and missed medication administrations were identified, including issues with medication passes and narcotic sign-off sheets.
Deficiencies (1)
19 CSR 30-85.042(46) Safe/Effective Medication System: The facility failed to administer or document medications for six of nine sampled residents, compromising medication safety and compliance.
Report Facts
Residents sampled: 9
Residents with medication issues: 6
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Barron | Senior Executive Director | Signed the statement of deficiencies and plan of correction. |
| MCM C | Interviewed regarding medication administration and documentation practices. | |
| Wellness Nurse E | Interviewed about medication administration process and staffing. | |
| MCM B | Interviewed about medication administration and shift coverage. | |
| Care Giver H | Interviewed about Certified Medication Technician (CMT) staffing on 12/25/23. |
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to nursing care and resident falls at Sunrise of Des Peres.
Findings
The facility failed to provide personal attention and nursing care consistent with residents' conditions, specifically failing to notify a nurse and assess residents after falls. Multiple resident falls were unwitnessed or improperly managed, and staff did not follow protocols for moving residents after falls.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Resident Condition. The facility failed to follow policy and notify a nurse regarding a resident's fall and failed to have a nurse assess the resident prior to moving them after an unwitnessed fall. This resulted in injuries and improper handling of residents following falls.
Report Facts
Resident census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Williams, Jr. | Legal Entity Representative | Signed the Plan of Correction |
| Nurse A | Mentioned in relation to fall incident and failure to assess resident | |
| CM B | Care Manager | Assisted in resident fall incident and investigation |
| CM C | Care Manager | Found resident on floor and assisted during fall incident |
| Nurse J | Mentioned regarding communication failures after resident fall | |
| Nurse L | Mentioned regarding resident transfer to hospital after fall | |
| Executive Director | Stated expectation that staff notify nurse following a fall |
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to protective oversight and nursing care following observations, interviews, and record reviews at Sunrise of Des Peres.
Findings
The facility failed to provide protective oversight for a resident who drank a non-acid disinfectant cleaner left unattended and unlocked. The facility also failed to assess a resident immediately when he complained of pain, resulting in delayed response and transfer to hospital.
Deficiencies (2)
A4074 19 CSR 30-85.042(65) Protective Oversight: The facility failed to provide protective oversight and supervision for a resident who drank non-acid disinfectant cleaner from an unattended and unlocked cleaning cart.
A4075 19 CSR 30-85.042(66) Nursing Care per Resident Condition: The facility failed to assess a resident immediately when he complained of pain in his right leg and continued to transfer him despite vocalized pain.
Report Facts
Census: 62
Sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Williams, Jr. | Executive Director | Signed Plan of Correction |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 9
Date: Jan 19, 2023
Visit Reason
Annual inspection conducted on 01/19/2023 to assess compliance with life safety, oxygen storage, fire alarm system, wastebasket standards, communicable disease employee screening, medication system, and food safety regulations at Sunrise of Des Peres.
Findings
The facility was found deficient in multiple areas including failure to operate and document monthly testing of Firefighter's Service on elevators, improper oxygen cylinder storage, unsecured fire alarm panel, use of non-approved wastebaskets, incomplete TB testing for employees, medication errors, unclean kitchen vents, improper food storage and labeling, and inadequate cleaning of kitchen equipment.
Deficiencies (9)
A1086 19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan: Facility failed to ensure monthly operation and documentation of Firefighter's Service for two elevators. This deficient practice could affect all occupants in the event of a fire.
A2010 19 CSR 30-85.022(6) Oxygen Storage: Facility failed to maintain oxygen cylinder storage according to NFPA code, including improper segregation of full and empty tanks. This had potential to affect occupants in one of nine smoke compartments.
A2019 19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Facility failed to secure fire alarm panel key, allowing unauthorized access to silence and reset functions. This could affect all occupants in the building.
A2071 19 CSR 30-85.022(40)(A) Wastebaskets, Metal/UL/FM: Facility used trashcans without UL or FM approval in resident areas, potentially affecting occupants in three smoke compartments.
A4031 19 CSR 30-85.042(27) Communicable Disease-Employees: Facility failed to ensure two-step PPD TB testing for four new employees, with no evidence of second-step tests completed.
A4055 19 CSR 30-85.042(46) Safe/Effective Medication System: Facility had two medication errors out of 29 opportunities, resulting in a 6.89% medication error rate affecting Resident #5.
A6019 19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: Facility failed to maintain kitchen ceiling vents free from dust buildup, affecting residents.
A7015 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility failed to ensure food items were properly covered, labeled, dated, and expired food discarded, potentially affecting all residents.
A7067 19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: Facility failed to maintain kitchen equipment clean, with grease and food buildup on range top, grill, and oven.
Report Facts
Resident census: 61
Medication error rate: 6.89
Number of medication errors: 2
Number of new employees missing second-step PPD: 4
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 1
Date: Oct 13, 2022
Visit Reason
The inspection was conducted to assess compliance with nursing care regulations, specifically regarding the use and management of CPAP and BiPAP respiratory devices for residents requiring respiratory support.
Findings
The facility failed to provide acceptable nursing care related to respiratory support devices by not obtaining physician orders and not updating individualized service plans for residents using CPAP or BiPAP machines. Several residents' medical records and care plans lacked proper documentation and orders for these devices.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: The facility failed to provide acceptable nursing care by not obtaining physician orders and not updating individualized service plans for residents using CPAP or BiPAP machines. This affected four sampled residents requiring respiratory support.
Report Facts
Resident census: 62
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Williams, Jr. | Executive Director | Signed the Plan of Correction |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 1
Date: Jan 21, 2022
Visit Reason
The document is a Plan of Correction submitted in response to a deficiency cited during a regulatory inspection of Sunrise of Des Peres related to nutritional needs and weight management.
Findings
The facility failed to provide fortified foods and health shakes per a physician's order to a resident with significant weight loss and failed to identify, assess, and notify a resident's physician after significant weight loss for two of three sampled residents. The census was 63 at the time of inspection.
Deficiencies (1)
19 CSR 30-85.052(1) Nutritional Needs Met, Assess Res, Inform Dr. The facility failed to provide fortified foods and health shakes per a physician's order to a resident with significant weight loss and failed to identify, assess, and notify a resident's physician after significant weight loss for two of three sampled residents.
Report Facts
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reema Chugh | Regional Director Of Operations | Signed the Plan of Correction |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 1
Date: Sep 1, 2021
Visit Reason
The document is a Plan of Correction related to a deficiency found during a survey regarding the facility's failure to maintain an employee disqualification list (EDL) for private duty care providers.
Findings
The facility failed to ensure a system was in place to conduct required employee disqualification list (EDL) checks for private duty care providers. One resident's personal caregiver was not properly screened through the EDL, and the facility lacked a system to monitor or maintain EDL checks for private duty care providers.
Deficiencies (1)
19 CSR 30-85.042(19) Employee/Volunteer Not on EDL. The facility failed to ensure a system was in place to conduct required employee disqualification list (EDL) checks for private duty care providers. One resident's personal caregiver was not on the EDL and the facility could not locate the caregiver's EDL search paperwork.
Report Facts
Resident census: 57
Sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ben Anderson | Executive Director | Named in relation to the deficiency regarding EDL checks and plan of correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jun 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to a resident burn injury caused by hot coffee served at the facility.
Complaint Details
The complaint investigation was substantiated with an imminent danger Class I violation related to a resident burn injury from hot coffee. The facility implemented corrective actions during the onsite exit visit.
Findings
The facility failed to provide protective oversight and proper nursing care for a resident who sustained significant burns from hot coffee. Staff were not trained or informed about safe coffee temperatures, and the resident's wounds were not properly assessed or treated in a timely manner. The facility also failed to ensure staff were trained on reporting suspected abuse and neglect.
Deficiencies (3)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: The facility failed to provide protective oversight for a resident who sustained significant burns from hot coffee served at unsafe temperatures. Staff used inappropriate equipment and did not report hot beverage temperatures to management.
19 CSR 30-85.042(67) Nursing Care Per Res Condition: The facility failed to provide acceptable nursing services for a resident with burn injuries, including delayed treatment, failure to complete orders, and inadequate pain management and wound monitoring.
19 CSR 30-88.010(24) Staff Trained on Reporting A/N: The facility failed to ensure staff were trained on reporting suspected abuse and neglect. A private duty staff member witnessed abuse but was not trained on reporting procedures.
Report Facts
Census: 56
Sample size: 4
Burn injury extent: 50
Burn injury extent: 6.25
Pain scale: 10
Pain scale: 5
Hours worked: 15.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ben Anderson | Executive Director | Named in plan of correction and interviews regarding coffee brewer service and oversight |
| CM J | Care Manager involved in resident care and interviews about the burn incident | |
| CM B | Care Manager involved in resident care and interviews about the burn incident | |
| Wellness Nurse A | Nurse involved in resident assessment and interviews about the burn incident | |
| Dishwasher M | Staff member interviewed about coffee temperature and serving practices | |
| CM S | Private duty staff member involved in abuse incident and reporting | |
| Care Manager S | Named in abuse incident and time sheet review |
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 2
Date: Dec 30, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care regulations, specifically related to resident care and fall risk management.
Findings
The facility failed to provide nursing care consistent with acceptable practice by not assessing resident risk for falls upon admission and after falls with injury. Documentation and assessments related to fall risk and post-fall evaluations were incomplete or missing for multiple residents.
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Resident Condition. The facility failed to assess resident risk for falls upon admission and after falls with injury, and failed to medically assess residents for changes in condition during the 72 hours following a fall with injury. Three residents with recent falls were included in the sample, and problems were found with all three.
19 CSR 30-85.042(103) Clinical Records Accurate/Accessible. The facility failed to maintain a complete comprehensive medical record for three out of three sampled residents who had falls and/or injuries.
Report Facts
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ben Anderson | Executive Director | Signed the plan of correction and mentioned in interview regarding fall policies |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 1
Date: Dec 18, 2018
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to properly transfer a resident, resulting in injury.
Findings
The facility failed to transfer a resident properly, resulting in an injury. The resident was paralyzed from the waist down and was transferred using a gait belt without a mechanical lift, leading to a fall and fracture requiring surgery.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Resident Condition: The facility failed to transfer a resident properly, resulting in injury. The resident was lowered to the floor without a mechanical lift, causing a fracture.
Report Facts
Resident census: 73
Date of survey: Dec 18, 2018
Plan of correction completion date: Jan 15, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Care Manager A | Named in transfer incident and interviews | |
| Care Manager H | Named in transfer incident and interviews | |
| Housekeeper G | Assisted in resident transfer and shower | |
| Licensed Practical Nurse (LPN) I | Licensed Practical Nurse | Interviewed regarding resident transfer and injury |
| Executive Director | Executive Director | Conducted refresher training and responsible for plan of correction |
Inspection Report
Census: 68
Deficiencies: 5
Date: Nov 28, 2018
Visit Reason
The inspection was conducted to identify deficiencies related to facility safety, medication administration, smoking area safety, nursing care, and toxic material storage at Sunrise of Des Peres.
Findings
The facility was found deficient in maintaining the kitchen range hood and fire suppression system, providing safe and effective medication administration, properly disposing of cigarette butts and ashtrays in the resident smoking area, ensuring adequate nursing care for residents with swallowing difficulties, and safely storing toxic materials. Multiple Class II and Class III deficiencies were cited.
Deficiencies (5)
19 CSR 30-85.022(9) Range Hood Certification. The facility failed to maintain the kitchen range hood to NFPA code, with grease and dust accumulation on filters and fire suppression nozzles.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal. The facility failed to provide ashtrays made of noncombustible material in the resident smoking area and failed to properly dispose of cigarette butts.
19 CSR 30-85.042(47) Safe/Effective Medication System. The facility failed to ensure a safe medication system by not following physician orders and improper insulin administration technique.
19 CSR 30-85.042(67) Nursing Care per Res Condition. The facility failed to provide adequate nursing care for residents with swallowing difficulties and did not properly document hospitalizations or therapy evaluations.
19 CSR 30-87.020(5) Toxic Material Storage. The facility failed to store poisonous or toxic materials in locked cabinets inaccessible to residents.
Report Facts
Census: 68
Inspection Report
Routine
Census: 69
Deficiencies: 4
Date: Jan 5, 2018
Visit Reason
Routine inspection conducted to assess compliance with regulations including written orders, nursing care, pressure sore prevention, and food safety at Sunrise of Des Peres facility.
Findings
The facility failed to obtain proper physician orders for catheter care, provide appropriate nursing assessments and interventions after falls, follow skin care and pressure sore prevention protocols, and maintain food safety standards. Multiple deficiencies were identified related to resident care and facility procedures.
Deficiencies (4)
19 CSR 30-85.042(46) Written Orders; Restraints: The facility failed to obtain physician's order for use, size, and care of a suprapubic catheter for one resident. No restraint orders were found.
19 CSR 30-85.042(67) Nursing Care per Res Condition: The facility failed to provide appropriate nursing assessment and interventions after a fall and ensure proper mechanical lift transfer techniques for two residents.
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: The facility failed to follow skin care program policy and provide timely wound care documentation for one resident with pressure sores.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to date fresh meat placed in the walk-in refrigerator, risking contamination of food served to residents.
Report Facts
Resident census: 69
Deficiencies cited: 4
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