Bethesda Dilworth
9645 Big Bend Blvd, Saint Louis, MO 63122 · Non profit - Corporation · 350 certified beds · (314) 968-5460 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $88,946 in federal fines (most recent 2025-04-11)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 22.2% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.2% | 5.3% | 5.4% | worse |
| 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 | 3.6% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.4% | 18.5% | 6.5% | better 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 | 6.6% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.4% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.1% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.3% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 62.9% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.5% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.0% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.90 | 2.33 | 1.80 | better |
‡ 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.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
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.
61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 431 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 180 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 36% 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 | 61.7%CMS range 57.3–66.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.7–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 62.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 47.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 91.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 number of residents or resident stays is too small to report. 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 | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.5%CMS range 3.8–8.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this 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 350 beds and averages 128.0 residents a day — about 37% occupied, or roughly 222 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.51 is at or above 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 4.46 hrs/resident/day on weekends vs 5.22 on weekdays — 15% thinner on weekends. RN hours go from 0.50 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
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 trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-04-11 · 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
Based on observation, interview and record review, the facility failed to ensure an acceptable skin management program was maintained to prevent pressure injury development and to report changes timely to the physician. The facility failed to complete wound assessments, including assessment and documentation of the location, stage, size, wound characteristics, periwound (the area around the wound) and wound edge description for two residents. (Residents #1 and #2). In addition, the facility failed to follow their policy for wound photographs and measurements for three residents (Resident #1, #2, and #3). The facility failed to contact Resident #1's physician prior to entering an order for a treatment. Additionally, the facility failed to follow their policy and complete a Situation, Background, Assessment, and Recommendation (SBAR) when new and/or worsening wounds were observed and failed to notify the physician and family for three residents (Resident #1, #2, and #3). Resident #1's pressure ulcer worsened, developing drainage and a foul odor. The resident required emergency surgery…
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 · G2024-05-23 · 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 interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when going to bed. On [DATE], after the resident became adamant about staff putting him/her to bed, staff removed the resident from a sit to stand lift (a medical device that assists individuals with limited mobility in standing up from a seated position) and performed a 2-person assist transfer. The resident's right foot was caught under the bed during the transfer and sustained a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the big toe) and lateral (the surface that corresponds to the pinky toe) tibial plateau without significant displacement. The sample size was 3. The census was 149. Review of the facility's Mechanical Lifts, Use of policy and…
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 before2026-03-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when the shift change narcotic count was not completed and one of the narcotic count sheets for one resident was inaccurate (Resident #7). The sample was 14. The census was 152 with 130 in certified beds. Review of the facility's Inventory Control of Controlled Substances Policy, revised 8/2023, showed:-Purpose: This policy sets forth the procedures for inventory control of controlled substances and establishes guidelines for the investigation of missing medications;-Scope: Level 2 policy affecting contracted pharmacies, Human Resources, nursing staff, and nursing management;-Responsibility: It will be the responsibility of the nursing staff members to know and comply with this policy and procedure. It is the responsibility of the Director of Nursing (DON) to maintain, enforce, and monitor compliance of this policy;-Policy: Practice processes will be followed to establish…
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 before2025-09-03 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · E2025-07-23 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's 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 ensure on-going resident centered therapeutic activities were provided to residents in the evenings and weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to all residents who wished to attend (Residents #140, #155 and #99). This deficient practice had the potential to affect all residents in the facility who wished to attend activites. The sample size was 25. The census was 145 with 126 in certified beds.1. During an interview on 7/23/25 at 8:31 A.M., the administrator said the Garden Terrace activity's calendar was the main calendar used for all activities in the facility. Review of the Garden Terrace Activity's Calendar, dated June 2025, showed: -Monday through Friday, no activities offered after 2:30 P.M.; -Saturdays, Catholic Mass at 10:30 A.M. in the chapel; -Sundays, no activities offered. Review of the Garden Terrace Activity's Calendar, dated July 2025,…
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 before2025-07-23 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to follow their grievance policy and procedure for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #9). The failure has the potential to affect all residents. The sample size was 13. The census was 146 with 119 in certified beds.Review of the facility's Resident and Family Grievances policy, revised, February 2025, showed: -Purpose: To establish written guidelines for the filing of residents' grievances and to ensure that appropriate investigation and actions are promptly taken; Customer feedback is an important source of information about an organization's performance; The verbal or written resident grievances received by staff, physicians, and administration provide vital information about improvement opportunities. -Definitions: A resident grievance is a formal or informal written or verbal complaint that is made to the facility by a resident, or the resident's representative, regarding the resident's care when the complaint is not resolved at the…
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 · D2025-07-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status for one of three residents investigated for hospice (Resident #147). The facility identified 19 residents on hospice. The census was 145 with 126 in certified beds. Review of Resident #147's medical record, showed diagnoses included dementia, Chronic Obstructive Pulmonary Disease (COPD, lung disease), depression, anxiety, and malnutrition;-An electronic physician order sheet (ePOS) showed an order dated [DATE], for a Hospice consult;-A hospice election form showed hospice services began [DATE]. Review of the resident's significant change MDS, dated [DATE], showed:-Assessment Reference Date (ARD) [DATE];-Special services received while a resident: Hospice Care not marked;-Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No. Review of…
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 · D2025-07-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 ensure two dependent residents received Activities of Daily Living (ADL) care (Residents #2 and #8). The sample was 25. The census was 145 with 126 in certified beds.Review of the facility's ADL care policy, dated October 2022, showed:-Purpose: To provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed;-Policy: It shall be the policy of the facility that each resident receives assistance with ADLs as needed throughout each day. Consideration will be given to making the experience as home-like and individual as possible;-Procedure: Give nail care as needed. Assist each resident with grooming. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/25, showed:-Diagnoses included anxiety and heart failure;-Cognitively intact;-Substantial/maximal assistance required for shower/bath;-Supervision or touch…
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 · D2025-04-11 · 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 three residents physician and the representative/appropriate family member after the residents had a change in condition (Resident #1, #2, and #3). The sample was 4. The census was 151. Review of the facility's policy, Reporting of Condition Changes, incidents and injuries, revised 1/23, showed: -Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents; -Responsibility: It will be the responsibility of the licensed nurses to know and follow this policy; -Policy: It is the facility policy to report condition changes, incidents or injuries involving residents; -Practice: When reporting changes in condition or incidents, the following procedure should be followed: -1. Evaluate symptoms and/or injury. Complete overall head to toe assessment including taking vital signs, temperature and neuro checks as indicated. Document assessment and findings on SBAR (communication tool- Situation,…
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 · D2025-01-29 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and 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 interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and needs, desire to be discharged , the resident's capacity for discharge, including caregiver support availability, capacity, and capability to perform required care, and failed to involve the resident, family member, and the interdisciplinary team (IDT) in developing a discharge plan, with interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition to the post-discharge setting and reduce factors leading to preventable readmissions. The facility failed to document and include the evaluation of the resident's discharge needs and failed to discuss the results of the evaluation with the resident and family, and incorporate it into the discharge plan, which is a part of the comprehensive care plan. The facility failed to discuss with the resident, and the family member, and document the implications…
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 before2025-01-29 · 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 interview and record review, the facility failed to provide pressure ulcer treatments as ordered and failed to notify the physician when the ulcer developed drainage and a foul odor, shortly before the resident was discharged . The resident was discharged to home, alone, without home health registered nursing care services, and without education or instructions of how to care for the coccyx/sacral wound. Five residents were sampled, and problems were identified with one (Resident #5). The census was 149. Review of the facility policy for Skin Integrity, Assessment, and Prevention of Wounds/Other Skin Conditions, revised on 9/2022, showed: -Purpose: -To prevent avoidable skin breakdown and pressure injuries; -Provide guidelines for the treatment of impaired skin; -Provide guidelines for documentation. -Policy: -All residents will be assessed for the risk of skin breakdown; -Risk factors identified will be evaluated; -Interventions will be developed and implemented to minimize or stabilize risk;…
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 · D2024-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 residents received care consistent with professional standards. Staff failed to ensure a resident admitted from the hospital with a peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart, used to administer long term antibiotics and other medications) line, had orders for the PICC line including PICC line maintenance. Staff failed to verify why the PICC line was in place and failed to obtain and ensure continuity of antibiotic administration from the hospital related to a bacterial infection. The resident was not administered antibiotic medication for two days after admission into the facility (Resident #1). In addition, the facility failed to ensure a resident admitted with a PICC line placed at the hospital on 8/23/24, when admitted to the facility received PICC line orders including PICC line…
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 12 citations
- Potential for harm · D2024-05-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 follow their abuse and neglect policy by not reporting timely after an incident involving one resident (Resident #1) and two staff, who performed an improper transfer which resulted in the resident sustaining a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the big toe) and lateral (the surface that corresponds to the pinky toe) tibial plateau without significant displacement. The sample size was 3. The census was 149. Review of the facility's Resident Abuse, Neglect, and Exploitation policy and procedure, revised 7/2023, showed: -Purpose: To provide guidelines for identifying, investigating, and reporting resident abuse, neglect, and exploitation, (which includes misappropriation of the resident's personal property) including any reasonable suspicion of a crime directed…
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 · D2024-03-13 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide an appropriate immediate discharge letter to one of four sampled residents (Resident #1). The letter failed to contain the effective date of discharge, specific location to where the resident was transferred and discharged , failed to provide information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, along with the failure to inform the resident he/she can return to the facility if an appeal is filed. Additionally, the Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The census was 147. Review of the facility's Discharge/Transfer of a Resident policy, dated 12/2022, showed: -The facility complies with federal regulations to permit each resident to remain in the community, and not transfer or discharge the resident unless: -The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the community; -The safety of the individuals in the community are endangered due…
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 before2023-09-29 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 a medication error rate of less than 5%. Out of 28 opportunities for errors, three errors occurred, resulting in a 10.71% medication error rate (Residents #11, #7 and #272). The sample was 26. The census was 148 with 129 in certified beds. Review of the facility's Medication Administration-General Guidelines Policy, revised 6/2023, showed: -Policy: Only a licensed nurse or Certified Medication Technician (CMT) may prepare, administer and/or record the administration of medications. Medications must be administered in accordance with a physician's order (i.e., the right resident, the right medication, the right dosage, the right route and the right time). Medications must always be prepared, administered and recorded by the same nurse/CMT; -Administration: -Each resident will have his/her own supply of medications, excluding stock medications; -Initial on Medication Administration Record (MAR) after each dose is administered; -After…
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 · E2023-09-29 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 residents who lived on the Rehab Unit were served hot foods at appropriate temperatures of at least 120 degrees Fahrenheit (F) at the time of service. Three residents were interviewed about food temperatures and all three said hot foods were frequently too cold (Residents #14, #172 and #173). The census was 148 with 129 in certified beds. Review of the facility's Meal Temperature policy, dated 1/21/21, showed the following: -Policy: All food items are evaluated for proper food temperature, taste and appearance prior to meal service. Food and drinks should be palatable, attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients'/residents' satisfaction; -Procedure: -When food is transported to a remote serving location such as a household, neighborhood, etc., final cook temperatures are taken and recorded in the kitchen; temperatures are taken and recorded again once transported…
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 · D2023-09-29 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 follow one resident's (Resident #222) wishes of Do Not Resuscitate (DNR, instructs health care providers not to do cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) if a patient's breathing or heartbeat has stopped). On [DATE] at 6:00 A.M., the resident was found on the floor, unresponsive and without a pulse. The nurse obtained the wrong chart and performed CPR on the resident for approximately 15 minutes prior to realizing the error. In addition, five out 26 residents reviewed for code status had code status/physician's orders for code status sheets not signed by the physician (Residents #102, #19, #99, #372, and #371). The census was 148 with 129 in certified beds. Review of the facility's Life Sustaining Treatment policy, last reviewed [DATE], showed: -Purpose: It is the purpose of this policy to help the facility honor a resident's wishes and comply with federal and state laws…
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 before2023-09-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their Inventory Control of Controlled Substances policy when staff failed to count/document daily controlled substances. 26 controlled substance shift change count sheets (narcotic sheets) were reviewed and issues were found with 18. The census was 148 with 129 in certified beds. Review of the facility's Inventory Control of Controlled Substances policy, last reviewed 8/2022, showed Community should ensure that incoming and outgoing nurses count all Scheduled II-V controlled substances (a drug or chemical whose manufacture, possession and use is regulated by a government) and Tramadol (medication used to treat pain) daily with both (staff) documenting verification on the Controlled Substance Log. 1. Review of the July 2023 Controlled Substance Shift Change Count sheet for the 2 Rehab Unit, showed 10 out of 31 opportunities had only one staff member's initials. Review of the July 2023 Controlled Substance Shift Change Count sheet for the 2 Rehab Unit (second sheet), showed 15 out of 31 opportunities had only one…
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 · D2023-09-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified five medication rooms, 10 medication carts, five treatment carts and one respiratory cart. Three of five medication rooms, two of five treatment carts, five out of ten medication carts and one of one respiratory carts were checked for medication storage. Issues were found with one medication room when staff failed to date one opened vial of purified protein derivative (PPD, used in skin test to help diagnose silent (latent) tuberculosis (TB) infection) and one treatment cart, when staff failed to date six out of 10 opened insulin pens and one medication cart and when staff failed to date one out of two opened insulin pens and stored one vial of PPD on the medication cart. The census was 148 with 129 in certified beds. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised on 10/31/16, showed; -Once any medication or biological…
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 · D2020-02-07 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 residents were able to self-administer medication only if the interdisciplinary team has determined that this practice is clinically appropriate, for one resident found to have medications left on the dining room table in front of the resident (Resident #73). The census was 201 with 164 in certified beds. Review of the facility's self-administration of medication policy, revised 8/2018, showed: -Policy: Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications and with administrator/executive director approval; -An evaluation will be completed and documented prior to allowing self-administration of medications, quarterly, with any change of condition or for any route not previously evaluated to be given; -The evaluation will be documented in the resident's medical record on the form; -If the evaluation indicates the resident may self-administer medications, the resident's or community…
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 · D2020-02-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 resident comprehensive care plans were implemented when staff failed to place fall mats beside a resident's bed and ensure Styrofoam plates were provided for a resident who threw plates, for two residents (Residents #99 and Resident #12) out of 32 sampled residents. The census was 201 with 164 in certified beds. 1. Review of Resident #99's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/19, showed: -Severe cognitive impairment; -One staff assist for bed mobility, transfers, dressing, toileting and personal hygiene; -Pain, yes; -Falls, yes, two or more; -Diagnoses included stroke. Review of the resident's care plan, in use during the survey, showed: -Focus: At risk for falls related to unsteady gait, surgical boot, weakness in legs, and overall increased assistance needed for activities of daily living related to end stage disease. Resident is on hospice, he/she…
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 · D2020-02-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 provided treatment in accordance with professional standards of care, when the facility administered a tube feeding for one resident (Resident #148) while the resident lay flat in the bed. The sample was 32. The census was 201 with 164 in certified beds. Review of Resident #148 admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed the following: -The resident had severe cognitive impairment; -The resident needed extensive to total assistance with grooming, dressing and bathing; -Nutritional approach was marked for feeding tube; -Diagnoses included high blood pressure, hemiplegia and hemiparesis (paralysis of the arm, leg and trunk on the same side of the body) following cerebral infarction (stroke) affecting left non-dominant side, dysphasia (deficiency on the generation of speech), dysphagia (swallowing difficulties), apraxia (inability to perform learned movement on command) following cerebral infarction, diabetes, and…
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 · D2020-02-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 the facility policy and ensure an indwelling urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) drainage bags remained off the floor for multiple days of the survey. The facility also failed to ensure a catheter drainage bag remained covered and unexposed to the hallway. This affected two of the five residents identified by the facility as having an indwelling urinary catheter (Residents #317 and #155). The census was 201 with 164 in certified beds. Review of the facility's catheter care policy, revised 4/2019, showed: -Purpose: To provide guidelines for proper care of the indwelling catheter and drainage bag to prevent complications; -Responsibility: It is the responsibility of all nursing staff to know and follow the procedure; -Policy: Catheter care is performed each shift and as needed to keep the catheter clean; -Catheter care practice: -Check the catheter drainage and tubing at the…
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 before2020-02-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 a medication error rate of less than 5%. Out of 25 opportunities observed, three errors occurred resulting in a 12% error rate (Resident #417). The census was 201 with 164 in certified beds. Review of the Resident #417's electronic physician order sheet (ePOS), showed: -An order dated 1/27/20, for amiloride (diuretic) 5 milligram (mg) daily; -An order dated 1/28/20, for Losartan (used to treat high blood pressure) 100 mg daily; -An order dated 2/3/20, for prednisone (steroid) 5 mg. Administer one tablet daily. During a medication administration observation on 2/5/20 at 8:18 A.M., Certified Medication Technician (CMT) B administered medications to the resident. He/she administered prednisone 5 mg, four tablets to equal 20 mg. He/she failed to administer amiloride and Losartan to the resident. Review of the resident's medication administration record, reviewed on 2/5/20 at 10:50 A.M., showed the resident's morning medications documented as administered at 8:20 A.M. Staff documented the resident's…
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.
- 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
$88,946 in federal fines across 1 penalty.
- $88,946 — penalty dated 2025-04-11
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 |
|---|---|---|---|
| BETHESDA LONG TERM CARE INC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/01/2006 |
| BRINKER, JOSEPH | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2010 |
| BYRNE, ROGER | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/10/2014 |
| ESTHER, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 01/01/2018 |
| FALKER, FRED | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 01/01/2022 |
| HUTCHISON, PHILIP | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2020 |
| KELLER, JOSEPH | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 01/01/2019 |
| KLINGLER, KEVIN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2024 |
| MAYES, GARY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 01/01/2023 |
| MCDONNELL, VERONICA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 04/25/2025 |
| MEIER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2019 |
| PEREGRIN, KIEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/23/2020 |
| ROONEY, PATRICK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2021 |
| ROWE, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 01/01/2025 |
| TEIBEL, SAMANTHA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 02/27/2025 |
| BETHESDA HEALTH GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/08/1999 |
| SELECT REHABILITATION, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/10/2025 |
| CWIKLOWSKI, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/04/2023 |
| DEMBIEC, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2025 |
| KIMBALL, MICHELE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/21/2021 |
| MCINTOSH, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/10/2025 |
| POPP, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/31/2025 |
CMS files one row per role, so the 51 rows in the source record cover these 22 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.
3 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
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 265764. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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.