St. Louis Altenheim

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment for residents when the facility failed to address a large water stain on the ceiling of one resident's room and bathroom (Resident #41). The facility also failed to ensure lights were in working order for one hallway on the 300 unit. The census was 47.1. Review of Resident #41's medical record, showed his/her diagnoses included arthritis, anxiety, depression and diabetes. Observation and interview on 10/7/25 at 11:10 A.M., showed the resident lay in bed. He/She said he/she has no concerns except for the underside of the soffit next to his/her television. There was a dark brown stain on the under part of the soffit that has a spider web type shape and extends approximately 6 inches long and 18 inches wide. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to obtain treatment orders timely and thoroughly document a new skin issue for one resident (Resident # 34) found with an untreated wound. The sample was 12. The facility census was 47. Review of the facility's, Pressure Ulcer/Skin Breakdown- Clinical Protocol Policy, dated April 2018, showed:-The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction); for example, immobility, recent weight loss, and a history of pressure ulcer(s);-In addition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (drainage) or necrotic (dead) tissue;b. Pain assessment;c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents when staff failed to follow facility policy regarding resident alcohol storage. One resident had several bottles of drinking alcohol, four mini wine bottles and a 16 ounce (oz) open beer in his/her mini fridge (Resident #25). The census was 47. The sample was 12. Review of the facilities Alcoholic Beverages Policy revised February 2023, showed purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents' personal refrigerators had routine temperature tracking (Residents #1 and #30). The facility also failed to ensure the kitchen ceiling above the food preparation station was free from dust accumulation and failed to ensure the walk- in freezer was free from ice buildup. The sample was 12. The census was 47. Review of the facility's sanitation policy, revised 11/22, showed:-Policy statement: the food service area is maintained in a clean and sanitary manner;-Policy implementation: all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide resident(s) the right to be informed and make choices about their care, when staff failed to inform a resident with dementia of the care to be provided and stop providing care when he/she yelled stop. Staff continued to provide care and mimicked or repeated residents' words the resident said during this time (Resident #35). The sample was 12. The census was 47. Review of the facility's Resident's Right Policy, dated February 2021, showed employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:-A dignified existence;-Be treated with respect, kindness, and dignity;-Be supported by the facility in exercising his or her rights. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was free from abuse when a Certified Nursing Assistant (CNA) hit a resident on the arm (Resident #4). The sample was 12. The census was 47. Review of the facility's abuse/neglect policy, revised 9/2022, showed:-Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported;-Policy implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status of having a life expectancy of less than 6 moths when they received hospice services (a service provided when a resident has a condition indicating a life expectancy of less than 6 months as certified by the hospice physician) for one of two residents investigated for hospice services (Resident #20). The census was 47. Review of Resident #20's medical record, showed:-Diagnoses included Alzheimer's Disease, diabetes, dementia, and major depressive disorder.-A Hospice Comprehensive assessment showed a hospice start of care date of 7/29/24 and current benefit dates 7/24/25-9/21/25.-The current certification of terminal illness dated 9/22/25-11/20/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for a dependent resident. The facility failed to ensure the resident received assistance in the dining room during meals and failed to ensure the resident's hands and nails were cleaned (Resident #4). The sample was 14. The census was 47. Review of the facility's ADL policy, revised 3/2018, showed:-Policy Statement: residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;-Policy implementation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards while providing perineal care for one resident (Resident #30). The sample was 12. The census was 47. Review of the facility's Perineal Care Policy, revised February 2018, showed:-Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.-Preparation:--Review the resident's care plan to assess for any special needs of the resident.--Assemble the equipment and supplies as needed.-Equipment and Supplies-The following equipment and supplies will be necessary when performing this procedure:--Wash basin;--Towels;--Washcloth;--Soap (or other authorized cleansing agent); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen was free from pests. The sample was 12. The census was 47. Review of the facility's pest control logs, showed:-On 9/25/25, the pest control company treated the facility and observed insects in the kitchen;-On 10/6/25 the pest control company changed out the facility pest traps. Observation on 10/7/25, of the kitchen, showed:-At 10:41 A.M., multiple flies flew around the bulk bin area. Observation on 10/9/25, of the kitchen, showed:-At 9:28 A.M., multiple flies near the clean pots and pans;-At 9:41 A.M., a beetle crawled on the ground next to the oven. During an interview on 10/10/25 at 8:43 A.M., Dietary Aide S said the kitchen has insects and a pest control company comes to spray. [...]