Cycle 1
Health 2024-07-18 · Fire 2024-07-18
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Saint Louis, MO
Bethesda Southgate
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
5943 Telegraph Road, Saint Louis, MO
(314) 846-2000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
78
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-04-03
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
0.60
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,694
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.57% · Performance 23.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.75
Baseline 5.95% · Performance 5.22% · Measure score 8.75 · Achievement 8.75 · Improvement 7.15
Total nurse turnover
7.07
Baseline 53.57% · Performance 34.78% · Measure score 7.07 · Achievement 7.07 · Improvement 6.04
Adjusted total nurse staffing
3.48
Baseline 4.73 hours · Performance 4.07 hours · Measure score 3.48 · Achievement 3.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 331 · Observed rate 8.76% · Lower 95% interval 6.89% |
| Discharge to community | 65.42% |
50.57%
14.9 pts better
|
Better than the National Rate · Eligible stays 346 · Observed rate 59.83% · Lower 95% interval 60.38% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.88% |
95.27%
0.6 pts better
|
Numerator 163 · Denominator 170 |
| Falls with major injury | 1.76% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 170 |
| Discharge self-care score | 52.67% |
53.69%
1 pts worse
|
Numerator 69 · Denominator 131 |
| Discharge mobility score | 69.47% |
50.94%
18.5 pts better
|
Numerator 91 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 0.59% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 170 · Adjusted rate 0.67% |
| Healthcare-associated infections requiring hospitalization | 5.22% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 3.21% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 3.36% |
8.2%
4.8 pts worse
|
Numerator 5 · Denominator 149 |
| Staff flu vaccination coverage | 98.73% |
42%
56.7 pts better
|
Numerator 155 · Denominator 157 |
| Discharge function score | 65.65% |
56.45%
9.2 pts better
|
Numerator 86 · Denominator 131 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 117 · Denominator 117 |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 42 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 4 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 44.7% |
84.8%
40.1 pts worse
|
93.4%
48.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 43.8% · Q3 40.9% · Q4 47.4% · 4Q avg 44.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
90.9%
7.1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
4.1%
3.7 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.3% · Q3 9.1% · Q4 7.9% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
14.7%
9.8 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.9% · Q3 2.6% · Q4 9.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.5%
0.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.3% · Q3 5.9% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
25.3%
11.6 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 13.5% · Q3 14.7% · Q4 14.3% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
25.0%
8.7 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.8% · Q3 17.4% · Q4 22.7% · 4Q avg 16.3% · 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 | 21.2% |
20.3%
0.9 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
19.8%
1.1 pts better
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 18.9% · Q3 11.8% · Q4 21.4% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.4%
0.5 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.6%
2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
18.1%
5.3 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 24.8% · Q3 22.4% · Q4 17.8% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.0%
1.5 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.2% · Q3 3.6% · Q4 6.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.4% |
66.4%
45 pts worse
|
81.7%
60.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 23.9% · Q3 23.6% · Q4 17.0% · 4Q avg 21.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
13.4%
5.2 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.1% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.4% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 17.2% |
63.5%
46.3 pts worse
|
79.7%
62.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 17.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
25.3%
5.3 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 28.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-03 · Fire 2022-11-03
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-09-25 · Fire 2019-09-25
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-07-18
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-07-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-07-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-07-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-07-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-07-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-30
F · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-05
E · Potential for more than minimal harm
2022-11-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-01
E · Potential for more than minimal harm
2022-11-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-01
E · Potential for more than minimal harm
2019-09-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-23
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-18
D · Potential for more than minimal harm
2024-07-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-18
D · Potential for more than minimal harm
2024-07-18
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 2024-08-18
D · Potential for more than minimal harm
2024-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-18
D · Potential for more than minimal harm
2024-07-18
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 2024-08-18
D · Potential for more than minimal harm
2022-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-01
D · Potential for more than minimal harm
2022-11-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-01
G · Actual harm
2019-09-25
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 2019-10-30
D · Potential for more than minimal harm
2019-09-25
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-25
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-25
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-25
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 2019-10-30
D · Potential for more than minimal harm
2019-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-30
Penalties and ownership
What sits behind the stars
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
Cosby, Darlene
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
Meier, John
Corporate Officer · Individual
Peregrin, Kiel
Operational/Managerial Control · Individual
Peregrin, Kiel
Corporate Officer · Individual
Popp, Jennifer
Operational/Managerial Control · Individual
Reynolds, Christopher
Operational/Managerial Control · Individual
Rolnick, Felice
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
Other facilities in reach
#1
Nazareth Living Center
Saint Louis, MO
1-star overall rating with 2-star inspections with $38,780 in total fines with 24 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Nexus at Columbia
Columbia, IL
1-star overall rating with 2-star inspections with abuse icon flag with $178,827 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Bluebird Wellness And Rehabilitation
Saint Louis, MO
1-star overall rating with 1-star inspections with $234,836 in total fines with 13 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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