Ignite Medical Resort St Peters
5101 Executive Centre Parkway, Saint Peters, MO 63376 · For profit - Limited Liability company · 91 certified beds · (636) 226-1900 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 2 actual-harm citations
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | Not rated |
| StaffingFrom payroll records (PBJ) | Not rated |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | Not rated |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.0% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.8% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 36.0% | 18.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 4.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 25.6% | 18.9% | better |
| Long-stay residents with pressure ulcers | 7.2% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.9% | 17.8% | 21.2% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 2.2% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 25.2% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.9% | 13.7% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.70 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 91 beds and averages 68.4 residents a day — about 75% occupied, or roughly 23 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 4.44 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gdisputed · IDR2026-05-20 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The resident's family reported the resident did not sleep well through the night due to his/her pain. The facility failed to ensure Resident #1 had scheduled acetaminophen (pain reliever and fever reducer) as ordered, within an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gdisputed · IDR2026-02-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: based on the comprehensive assessment of the resident, facility clinical staff will ensure that the resident who enters the facility without pressure injury will not develop pressure injury unless the resident's clinical condition demonstrates that the condition was unavoidable;-The licensed nurse and interdisciplinary team (IDT) will assess and periodically reassess each resident's risk for developing pressure ulcer and take actions to address any identified risks;-The IDT will create a written plan for the identification of risk for and prevention of pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-16 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Ecited before2026-04-16 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Ecited before2026-04-16 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Ecited before2026-04-16 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2026-04-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2026-04-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2026-04-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Dcited before2026-04-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · Ecited before2026-03-10 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility did not provide a policy for resident change of condition or information to report to emergency personnel when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Every resident will be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility;-Use of the temporary, initial care plan and communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · Fcited before2026-02-24 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Review of the facility's policy, Facility Assessment, dated 8/01/24, showed the following:-The facility will evaluate the resident population and identify the resources needed to provide the necessary care and service the residents require on an annual basis and at any time any significant changes are made to the care or services provided in the facility;-The purpose of the Facility Assessment included but was not limited to inform staffing decisions to ensure sufficient staff with appropriate competencies and skill sets necessary to care for all residents' needs as identified through resident assessments and care plans as required, consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to the resident population,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-24 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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). Review of the resident's Progress Notes, dated 1/13/26, showed the following:-Chest x-ray results received and showed pneumonia;-Doxycycline (antibiotic) 100 milligrams (mg) twice a day (BID) for five…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Review of the resident's medical record showed no documentation regarding the resident's preference for bathing/showers and no documentation to show how frequently the resident was to receive bathing/showers.Review of the resident's Point of Care (POC, a place in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-24 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the unsigned Facility Assessment, dated 6/21/24, showed the following:-Ember and [NAME] hallways: Staffing is adjusted dependent on the volume of the unit for short-term patients with a focus on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Observation on 2/23/26 at 7:35 P.M., showed the following:-Eighteen medication cards were stacked on top of the desk at the nurses station; -Five medication bottles sat unattended on top of the treatment cart at the nurse's station; -The treatment cart was not in use and was in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The wheelchair would not fit through the door to the bathroom in the resident's room;-The resident had a regular sized bed pan. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the facility policy, Change in Resident Condition, revised April 2023, showed the following:-Should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified;-Documentation will be present in the resident's record. 1. Review of Resident #17's care plan,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: a significant weight change of 5% or more in one month, 7.5% or more in three months and/or 10% or more in six months;-Once the weight change investigation is completed, the dietician and the physician will be contacted for interventions;-The interventions will be updated in the resident chart and if appropriate, the resident or resident's representative will be notified of the interventions;-If the resident or resident representative refuses any of the interventions, education regarding rationale for the interventions will be given. If they continue…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Review of the facility policy Administration of Medications, dated April 2023, showed the following:-All medications are administered safely and appropriately, to aid residents to help with and overcome illness, relieve and prevent symptoms and help in diagnosis;-A physician or nurse practitioner order is required for administration of all medication;-If a medication is not administered, record the reason on the electronic Medication Administration Record (MAR) and notify the physician or nurse practitioner;-If a medication is ordered but not available, check to see if it was misplaced and then call…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-24 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. showed the following:-The resident and Family Member (FM) B in the resident's room;-FM B said the resident arrived at the facility on 02/23/26 at 5:55 P.M. from a local hospital for therapy due to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of the facility policy, Enhanced Barrier Precautions (EBP), dated March 2024, showed the following:-EBP is implemented as an intervention this facility uses to reduce transmission of resistant organisms that employs targeted PPE use during high contact resident care activities;-EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2026-04-01 for 40 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| IMR ST PETERS HOLDINGS, LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/22/2024 |
| IGNITE ST PETERS JV, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/15/2025 |
| KCB ST PETERS TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/15/2025 |
| LBG ST PETERS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/15/2025 |
| ST. PETERS SENIOR INVESTORS, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/15/2025 |
| BERTSCH, TROY | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| BROWN, LEO | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| CARR, BARRY | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| CARR, JARED | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| FIELDS, TIMOTHY | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| GILLIS, KAREN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| GOBST, RYAN | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| JABLONSKI, NICOLE | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| KING, CHRISTOPHER | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| MCFARLANE, JOHN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| MORTON, WILLIAM | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| RAINEY, SHAWNA | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| ROGERS, DYLAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| ROSE, MARC | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| SEE, KEVIN | Individual | INDIRECT OWNERSHIP INTEREST | since 08/15/2025 |
| SMITH, THOMAS | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | since 08/15/2025 |
| THENGIL, MATHEW | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| WAGNER, MICHAEL | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | since 08/15/2025 |
| WHITE, JIM | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| IGNITE TEAM PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/08/2025 |
| SPARK THERAPY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/08/2025 |
| LANE, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| MABINS, ZENA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2025 |
| MALIK, RAMEEZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2025 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 08/15/2025 |
CMS files one row per role, so the 66 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265889. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.