Saint Louis, MO

Friendship Village Sunset Hills

4-star overall rating with 3-star inspections with $14,433 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

12651 Village Circle Drive, Saint Louis, MO

(314) 270-7777

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

144

Certified beds

Average residents

135

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1978-12-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.59

Registered nurse staffing · state 0.46 · national 0.68

LPN hours / resident day

1.01

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.72

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

4.32

All reported nurse hours · state 3.47 · national 3.89

Licensed hours

1.60

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

0.46

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.66

CMS adjusted RN staffing hours

Adjusted total hours

4.82

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

28%

Annual RN turnover · state 51% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 57% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,937

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.53

Composite VBP score used to determine payment impact.

Payment multiplier

0.9884

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.46% · Performance 21.29% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.44

Baseline 5.60% · Performance 6.21% · Measure score 5.44 · Achievement 5.44 · Improvement 0

Total nurse turnover

3.52

Baseline 56.52% · Performance 49.29% · Measure score 3.52 · Achievement 3.52 · Improvement 1.78

Adjusted total nurse staffing

4.86

Baseline 4.04 hours · Performance 4.46 hours · Measure score 4.86 · Achievement 4.86 · Improvement 1.89

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.26%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 250 · Observed rate 10% · Lower 95% interval 8.37%
Discharge to community	53.54%	50.57% 3 pts better	No Different than the National Rate · Eligible stays 236 · Observed rate 50.85% · Lower 95% interval 47.31%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	98.96%	95.27% 3.7 pts better	Numerator 95 · Denominator 96
Falls with major injury	1.04%	0.77% 0.3 pts worse	Numerator 1 · Denominator 96
Discharge self-care score	51.22%	53.69% 2.5 pts worse	Numerator 42 · Denominator 82
Discharge mobility score	37.8%	50.94% 13.1 pts worse	Numerator 31 · Denominator 82
Pressure ulcers or injuries, new or worsened	2.08%	2.29% 0.2 pts better	Numerator 2 · Denominator 96 · Adjusted rate 2.26%
Healthcare-associated infections requiring hospitalization	6.21%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 112 · Observed rate 3.57% · Lower 95% interval 3.62%
Staff COVID-19 vaccination coverage	2.5%	8.2% 5.7 pts worse	Numerator 7 · Denominator 280
Staff flu vaccination coverage	77.78%	42% 35.8 pts better	Numerator 273 · Denominator 351
Discharge function score	57.32%	56.45% 0.9 pts better	Numerator 47 · Denominator 82
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	98.33%	96.28% 2 pts better	Numerator 59 · Denominator 60
Resident COVID-19 vaccinations up to date	48.89%	25.2% 23.7 pts better	Numerator 22 · Denominator 45

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	2.1 0.2 pts better	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.4 · 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 0.5 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.0%	84.8% 10.2 pts better	93.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 95.8% · Q3 93.7% · Q4 93.2% · 4Q avg 95.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	90.9% 9.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	6.5%	4.1% 2.4 pts worse	3.3% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.8% · Q3 8.1% · Q4 6.0% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.5%	14.7% 14.2 pts better	11.4% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.9% · 4Q avg 0.5%
Percentage of long-stay residents who lose too much weight	0.6%	5.5% 4.9 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.4%	25.3% 11.9 pts better	19.6% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 16.1% · Q3 9.8% · Q4 13.4% · 4Q avg 13.4%
Percentage of long-stay residents who received an antipsychotic medication	8.9%	25.0% 16.1 pts better	16.7% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 4.6% · Q3 7.8% · Q4 10.6% · 4Q avg 8.9% · 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	13.8%	20.3% 6.5 pts better	16.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 19.8% · Q3 11.9% · Q4 15.7% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.6%	19.8% 9.2 pts better	14.9% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 9.6% · Q3 11.2% · Q4 10.1% · 4Q avg 10.6% · 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 0.0% · Q2 0.8% · Q3 0.7% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	2.6% 0.4 pts better	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.3% · Q3 3.6% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	11.3%	18.1% 6.8 pts better	19.8% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.0% · Q3 8.0% · Q4 13.6% · 4Q avg 11.3%
Percentage of long-stay residents with pressure ulcers	5.1%	5.0% 0.1 pts worse	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.2% · Q3 5.4% · Q4 5.9% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	72.3%	66.4% 5.9 pts better	81.7% 9.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 76.3% · Q2 72.9% · Q3 73.2% · Q4 67.3% · 4Q avg 72.3%
Percentage of short-stay residents who had an outpatient emergency department visit	8.0%	13.4% 5.4 pts better	12.0% 4 pts better	Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.2% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	2.2% 0.8 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.0% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.1%	63.5% 12.6 pts better	79.7% 3.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.0%	25.3% 6.3 pts better	23.9% 4.9 pts better	Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 13.3% · Expected 16.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-28 · Fire 2025-01-28

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-09-28 · Fire 2023-09-28

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-08-28 · Fire 2019-08-28

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 2025-01-28

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2025-02-13

F · Potential for more than minimal harm 2025-01-28

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-02-13

E · Potential for more than minimal harm 2019-08-28

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-10-04

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-28

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 2025-03-14

E · Potential for more than minimal harm 2025-01-28

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-02-28

E · Potential for more than minimal harm 2025-01-28

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 2025-03-14

E · Potential for more than minimal harm 2025-01-28

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-28

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 2025-03-14

D · Potential for more than minimal harm 2025-01-28

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-28

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-28

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-01-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-14

J · Immediate jeopardy 2024-04-15

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-03-18

G · Actual harm 2024-02-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-23

F · Potential for more than minimal harm 2023-09-28

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 2023-11-12