Ignite Medical Resort St. Peters

Inspectors wroteBased on interview and record review, the facility failed to provide an effective pain management program for two residents (Resident #4 and #1), in a review of four sampled residents. The facility failed to consistently monitor the effectiveness of pain medication following administration to Resident #4 and to administer as needed (PRN) pain medication to ensure the resident's pain was controlled. The facility failed to ensure Resident #4 had effective pain management when he/she was out of his/her oxycodone (opioid pain reliever) from 05/16/26 until 05/20/26 and his/her pain was not controlled. The resident frequently rated his/her pain as an eight or higher (on a pain scale of 0-10 with 10 being the most pain) and staff identified the resident's pain affected his/her mood and emotions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice for three residents (Resident #1, #2, and #6), when staff failed to complete neurological assessments (to detect brain injury), for two residents (Resident #1and #6) who sustained falls of seven sampled residents. Staff failed to do complete a thorough assessment, provide first aid and stay with Resident #1 following a fall with injury to the head. Staff failed to provide a report to emergency personnel who responded to transport the resident to the hospital. The facility also failed to monitor Resident #2 after the resident experienced a change in condition and developed a blood clot in the leg. The facility failed to provide a report to emergency personnel with pertinent health history information when they were on scene to transport the resident to the hospital. The census was 69. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to plan care to address one resident's (Resident #1) of seven sampled residents, risk for falls. The facility assessed the resident for high fall risk with no care plan addressing falls. The resident fell from bed on 3/1/26 and sustained a laceration to the head. The facility failed to plan care after the resident's fall to prevent further falls. The facility census was 69. Review of the facility policy for Fall Prevention dated 11/20 showed the following:-Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains free from accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #11) of 18 sampled residents received the necessary care and services including appropriate individualized interventions to prevent the development and identification of a Stage 3 pressure ulcer on the resident's buttock. The facility census was 77. Review of the facility policy for Skin Policy and Procedure dated 3/20 showed the following:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive facility assessment specific to the facility and failed to ensure the assessment determined the appropriate number of staff and resources needed to care for the residents within the facility. The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications as ordered on admission for two residents (Resident #2 and #9), in a review of 18 sampled residents. The facility census was 77. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when the medications were not available. 1. Review of Resident #2's Face Sheet showed the resident's diagnoses included Type 2 diabetes mellitus, pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus) and coronavirus (COVID; highly contagious respiratory virus). Review of the resident's January 2026 Physician Order Sheet (POS) showed an order for stat (immediate) chest x-ray one time for shortness of breath and hypoxia (low oxygen levels) (ordered 1/13/26). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good hygiene for three residents (Residents #4, #5 and #6), who required assistance with bathing, in a review of 23 sampled residents. The facility census was 70. Review of the facility policy for bathing, revised April 2023, showed all residents received a bath or a shower in accordance with their preferences. If the residents do not provide a preference, staff will offer a bath or a shower.1. Review of Resident #4's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), dated 3/30/26, showed the following:-Alert and oriented and able to make decisions;-Dependent on staff for bathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the residents' needs for ten residents (Residents #4, #5, #6, #2, #4, #8, #7, #10, #12 and #1), in a review of 23 sampled residents. Staff failed to provide routine showers for three residents (Residents #4, #5 and #6) to ensure good personal hygiene, failed to provide supervision while eating for three residents (Residents #2, #4, and #8) as directed in their plan of care, failed to assist three residents (Residents #7, #10 and #12) timely with a breakfast meal, failed to administer medications timely for one resident (Resident #1), and failed to ensure the Director of Nursing (DON) did not function as a charge nurse when the facility census was greater than 60. The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications behind at least one locked door or cabinet when staff left medications unattended on the nurses station and treatment cart and failed to lock treatment and medication carts when unattended. The facility failed to secure medications for one resident (Resident #9), in a review of 18 sampled residents. The facility census was 77. Review of the undated facility policy, Medication Labeling and Storage, showed medications and biologicals in medication rooms, carts, boxes and refrigerators are maintained within secured (locked) locations, accessible only to designated staff. Review of the facility policy, Administration of Medications, revised April 2023, showed to never leave the medication cart open and unattended. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary equipment was available, upon admission, for one resident (Resident #9), in a review of 23 sampled residents, to safely transfer the resident in/out of bed and to complete bathing and toileting needs. The facility census was 70. The facility did not provide policies related to accommodation of needs and equipment to meet the residents' needs. 1. Review of Resident #9's undated face sheet showed the resident admitted to the facility on [DATE] with a diagnosis of morbid obesity. Review of the resident's hospital discharge records, dated 04/14/26, showed on 03/27/26 the resident weighed 574 pounds. Observation on 04/15/26 at 8:30 A.M. in the resident's room showed the following:-The resident had a bariatric wheelchair that measured 35 inches across the seat of the wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify two residents' physician or family of a change in the residents' condition. Staff failed to notify Resident #17's physician when staff did not obtain daily weights as ordered, failed to notify the physician of weight gain as directed by the physician's ordered parameters, and failed to notify the physician when the resident's diuretic medication was unavailable for administration. Staff failed to notify Resident #15's family when the resident was transferred to the emergency department for treatment of hypoglycemia (low blood sugar). This deficient practice affected two out of 23 sampled residents. The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, evaluate and modify interventions to prevent weight loss for one resident (Resident #18) of eighteen sampled residents. The resident experienced a 13.98% weight loss in two months. The census was 77. Review of the facility policy for Weight Change Investigation with a revision date of 05/2023 showed the following:-The weight change investigation will be initiated with the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to administer medications without a significant medication error to one resident (Resident #17), in a review of 23 sampled residents, when staff failed to administer the resident's diuretic medications (medications used to remove excess fluid from the body) as ordered by the resident's physician from 03/20/26 through 04/04/26 resulting in an exacerbation of lower extremity edema and shortness of breath. The facility census was 70. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident (Resident #10), in a sample of 18 residents with an evening meal. The resident admitted to the facility on the evening shift and staff provided no meal tray for the resident. The resident's family had to go to a local restaurant and bring food to the resident. The census was 77. The facility did not provide a policy for meal service to new admissions upon request. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of fracture pelvis, respiratory failure and protein-calorie malnutrition. Review of the resident's physician order sheet dated 02/23/26, showed a diet order of a regular diet with mechanical soft foods. Observation and interview on 02/23/26 at 7:27 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate infection control measures for two residents (Residents #1 and #11), in a review of 18 sampled residents, when staff did not utilize enhanced barrier precautions (EBP, an infection control strategy in nursing homes that expands the use of personal protective equipment (PPE), specifically gowns and gloves, for high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs)), as directed in the facility policy. The facility census was 77. [...]