Ignite Medical Resort St Peters

In the surveyor’s words

From the most serious findings on record at Ignite Medical Resort St Peters, in the surveyor’s own words.

• Actual harm, isolatedF697May 20, 2026

  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. […]

• Actual harm, isolatedF686Feb 24, 2026

  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… […]

• No harm, potential for more than minimal, widespreadF838Feb 24, 2026

  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… […]

• No harm, potential for more than minimal, patternF658Mar 10, 2026

  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. […]

• No harm, potential for more than minimal, patternF677Feb 24, 2026

  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. […]