Cycle 1
Health 2025-03-28 · Fire 2025-03-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Saint Louis, MO
Christian Extended Care & Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
11160 Village North Drive, Saint Louis, MO
(314) 355-8010
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Bjc Healthcare
Operator or chain grouping
Approved since
1982-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 4 staffing / 2 quality stars
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
0.58
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.12
Baseline 18.45% · Performance 20.45% · Measure score 2.12 · Achievement 2.12 · Improvement 0
Healthcare-associated infections
4.51
Baseline 6.31% · Performance 6.49% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Total nurse turnover
2.75
Baseline 50.00% · Performance 52.46% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Adjusted total nurse staffing
1.69
Baseline 2.88 hours · Performance 3.52 hours · Measure score 1.69 · Achievement 1.54 · Improvement 1.69
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 172 · Observed rate 11.63% · Lower 95% interval 7.54% |
| Discharge to community | 61.71% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 183 · Observed rate 53.01% · Lower 95% interval 56.12% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 89.13% |
95.27%
6.1 pts worse
|
Numerator 82 · Denominator 92 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 92 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 35 · Denominator 63 |
| Discharge mobility score | 34.92% |
50.94%
16 pts worse
|
Numerator 22 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 5.32% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 28.41% |
8.2%
20.2 pts better
|
Numerator 25 · Denominator 88 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 102 · Denominator 102 |
| Discharge function score | 47.62% |
56.45%
8.8 pts worse
|
Numerator 30 · Denominator 63 |
| Transfer of health information to provider | 89.71% |
95.95%
6.2 pts worse
|
Numerator 61 · Denominator 68 |
| Transfer of health information to patient | 80% |
96.28%
16.3 pts worse
|
Numerator 16 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 15.22% |
25.2%
10 pts worse
|
Numerator 7 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
84.8%
2.5 pts worse
|
93.4%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 82.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.1%
4.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
25.3%
19.4 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.5% |
25.0%
20.5 pts better
|
16.7%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.9% |
19.8%
22.1 pts worse
|
14.9%
27 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.6%
0.6 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
18.1%
11.1 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.0%
5 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.2% |
66.4%
0.2 pts worse
|
81.7%
15.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 65.9% · Q3 61.9% · Q4 62.7% · 4Q avg 66.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
13.4%
0.4 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.2%
1.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.6% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.4% |
63.5%
2.9 pts better
|
79.7%
13.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
25.3%
4.3 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 28.4% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-13 · Fire 2023-10-13
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-09-23 · Fire 2020-09-23
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-02
F · Potential for more than minimal harm
2023-10-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-29
E · Potential for more than minimal harm
2023-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-10
E · Potential for more than minimal harm
2020-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-10-31
E · Potential for more than minimal harm
2020-09-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-10-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-28
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 2025-05-02
F · Potential for more than minimal harm
2023-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-13
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 2023-11-03
C · Minimal harm
2023-10-13
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-11-03
C · Minimal harm
2023-10-13
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 2023-11-03
D · Potential for more than minimal harm
2023-04-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-19
E · Potential for more than minimal harm
2020-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-11-10
D · Potential for more than minimal harm
2020-09-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-11-10
D · Potential for more than minimal harm
2020-09-23
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 2020-11-10
D · Potential for more than minimal harm
2020-09-23
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 2020-11-10
B · Minimal harm
2020-09-23
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 2020-11-10
Penalties and ownership
What sits behind the stars
Ownership
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 Director · Individual
Byrne, Roger
Corporate Officer · Individual
Christian Health Services Development Corporation
Operational/Managerial Control · Organization
Hogan, Billy
Operational/Managerial Control · Individual
Magruder, Joan
Operational/Managerial Control · Individual
Magruder, Joan
Corporate Director · Individual
Magruder, Joan
Corporate Officer · Individual
Malik, Rameez
Operational/Managerial Control · Individual
Malik, Rameez
Corporate Director · Individual
Stevens, Ricky
Operational/Managerial Control · Individual
Stevens, Ricky
Corporate Director · Individual
Stevens, Ricky
Corporate Officer · Individual
Turner, Geoffrey
Operational/Managerial Control · Individual
Turner, Geoffrey
Corporate Director · Individual
Village North Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Atrium Place Health And Rehabilitation
Saint Louis, MO
2-star overall rating with 2-star inspections with $189,778 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Hidden Lake Health Care Center
Saint Louis, MO
1-star overall rating with 1-star inspections with $123,610 in total fines with 25 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Crestwood Health Care Center, LLC
Florissant, MO
1-star overall rating with 1-star inspections with abuse icon flag with $155,928 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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