Cycle 1
Health 2025-07-23 · Fire 2025-07-23
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Saint Louis, MO
Bethesda Dilworth
2-star overall rating with 2-star inspections with $90,599 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
9645 Big Bend Blvd, Saint Louis, MO
(314) 968-5460
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
350
Certified beds
Average residents
129
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.37
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.81
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,408
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.11
Baseline 22.68% · Performance 21.77% · Measure score 1.11 · Achievement 0 · Improvement 1.11
Healthcare-associated infections
7.99
Baseline 7.22% · Performance 5.45% · Measure score 7.99 · Achievement 7.99 · Improvement 7.47
Total nurse turnover
4.04
Baseline 57.95% · Performance 47.17% · Measure score 4.04 · Achievement 4.04 · Improvement 2.76
Adjusted total nurse staffing
6.82
Baseline 4.50 hours · Performance 5.02 hours · Measure score 6.82 · Achievement 6.82 · Improvement 3.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 413 · Observed rate 11.14% · Lower 95% interval 8.67% |
| Discharge to community | 61.74% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 431 · Observed rate 54.76% · Lower 95% interval 57.34% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.42% |
95.27%
0.8 pts worse
|
Numerator 237 · Denominator 251 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 3 · Denominator 251 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 108 · Denominator 180 |
| Discharge mobility score | 46.11% |
50.94%
4.8 pts worse
|
Numerator 83 · Denominator 180 |
| Pressure ulcers or injuries, new or worsened | 6.77% |
2.29%
4.5 pts worse
|
Numerator 17 · Denominator 251 · Adjusted rate 6.92% |
| Healthcare-associated infections requiring hospitalization | 5.45% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 4% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 244 |
| Staff flu vaccination coverage | 76.27% |
42%
34.3 pts better
|
Numerator 180 · Denominator 236 |
| Discharge function score | 59.44% |
56.45%
3 pts better
|
Numerator 107 · Denominator 180 |
| Transfer of health information to provider | 97.18% |
95.95%
1.2 pts better
|
Numerator 172 · Denominator 177 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 27 · Denominator 135 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
84.8%
0.9 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 86.1% · Q3 83.1% · Q4 76.5% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
90.9%
6.8 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.2% |
4.1%
5.1 pts worse
|
3.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 11.4% · Q3 8.4% · Q4 7.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 14.3% |
5.5%
8.8 pts worse
|
5.4%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 24.2% · Q3 5.9% · Q4 9.1% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
25.3%
5.4 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 20.6% · Q3 22.1% · Q4 19.4% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
25.0%
17 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.8% · Q3 12.2% · Q4 8.5% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.6% |
20.3%
4.3 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 32.0% · Q3 14.7% · Q4 21.9% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
19.8%
1.9 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 29.9% · Q3 17.9% · Q4 19.7% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.4%
0.9 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.6% · Q3 2.4% · Q4 6.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
18.1%
12 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 36.4% · Q3 32.6% · Q4 20.0% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.0%
3.2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.1% · Q3 8.6% · Q4 12.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 48.0% |
66.4%
18.4 pts worse
|
81.7%
33.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.8% · Q2 55.4% · Q3 39.9% · Q4 36.5% · 4Q avg 48.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
13.4%
2.2 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.2%
1.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 0.4% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.9% |
63.5%
0.6 pts worse
|
79.7%
16.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
25.3%
0.1 pts better
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 24.3% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-29 · Fire 2023-09-29
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-02-07 · Fire 2020-02-07
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-06
E · Potential for more than minimal harm
2025-07-23
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-07-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-24
F · Potential for more than minimal harm
2023-09-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-09-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-27
F · Potential for more than minimal harm
2020-02-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-03-06
E · Potential for more than minimal harm
2020-02-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-06
E · Potential for more than minimal harm
2020-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-06
E · Potential for more than minimal harm
2020-02-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-03-06
E · Potential for more than minimal harm
2020-02-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-03
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-07-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-07-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-29
J · Immediate jeopardy
2025-04-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-04-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-01-29
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-30
G · Actual harm
2024-05-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-03-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-09-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-29
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-29
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2023-10-27
D · Potential for more than minimal harm
2020-02-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-06
Penalties and ownership
What sits behind the stars
$90,599
2025-04-11
Fine
Fine · fine $90,599
Fine
Ownership
Bethesda Long Term Care Inc
5% Or Greater Direct Ownership Interest · Organization
Bethesda Health Group Inc
Operational/Managerial Control · Organization
Brinker, Joseph
Operational/Managerial Control · Individual
Brinker, Joseph
Corporate Director · Individual
Brinker, Joseph
Corporate Officer · Individual
Byrne, Roger
Operational/Managerial Control · Individual
Byrne, Roger
Corporate Officer · Individual
Cwiklowski, Renee
Operational/Managerial Control · Individual
Dembiec, Scott
Operational/Managerial Control · Individual
Esther, James
Corporate Director · Individual
Falker, Fred
Corporate Director · Individual
Hutchison, Philip
Corporate Officer · Individual
Keller, Joseph
Corporate Director · Individual
Kimball, Michele
Operational/Managerial Control · Individual
Klingler, Kevin
Corporate Officer · Individual
Mayes, Gary
Corporate Director · Individual
Mcdonnell, Veronica
Corporate Director · Individual
Mcintosh, Jessica
Operational/Managerial Control · Individual
Meier, John
Corporate Officer · Individual
Peregrin, Kiel
Operational/Managerial Control · Individual
Peregrin, Kiel
Corporate Officer · Individual
Popp, Jennifer
Operational/Managerial Control · Individual
Rooney, Patrick
Corporate Officer · Individual
Rowe, John
Corporate Director · Individual
Select Rehabilitation, LLC
Operational/Managerial Control · Organization
Teibel, Samantha
Corporate Director · Individual
Nearby options
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Grove At Kirkwood, The
Kirkwood, MO
1-star overall rating with 1-star inspections with 28 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Aberdeen Heights
Kirkwood, MO
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Mary, Queen And Mother Center
Shrewsbury, MO
2-star overall rating with 2-star inspections with $19,133 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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