28 health deficiencies
Top issue: Resident Rights (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Kirkwood, MO
1-star overall rating with 1-star inspections with 28 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
711 South Kirkwood Road, Kirkwood, MO
(314) 965-0864
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
117
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-02-01
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
RN hours / resident day
0.60
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.96
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
6.01
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
2.56
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
5.66
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
6.50
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
9,034
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.07
Baseline 23.82% · Performance 22.75% · Measure score 1.07 · Achievement 0 · Improvement 1.07
Healthcare-associated infections
3.02
Baseline 7.00% · Performance 6.93% · Measure score 3.02 · Achievement 3.02 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.39
Baseline 5.43 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 7.56% · Lower 95% interval 6.66% |
| Discharge to community | 53.46% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 49.57% · Lower 95% interval 44.23% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.33% |
95.27%
2.1 pts better
|
Numerator 73 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 45.1% |
53.69%
8.6 pts worse
|
Numerator 23 · Denominator 51 |
| Discharge mobility score | 27.45% |
50.94%
23.5 pts worse
|
Numerator 14 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 8% |
2.29%
5.7 pts worse
|
Numerator 6 · Denominator 75 · Adjusted rate 7.08% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 5.33% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 130 |
| Staff flu vaccination coverage | 53.44% |
42%
11.4 pts better
|
Numerator 70 · Denominator 131 |
| Discharge function score | 35.29% |
56.45%
21.2 pts worse
|
Numerator 18 · Denominator 51 |
| Transfer of health information to provider | 97.92% |
95.95%
2 pts better
|
Numerator 47 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 65.63% |
25.2%
40.4 pts better
|
Numerator 21 · Denominator 32 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
84.8%
14.5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.5% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
90.9%
6.2 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
4.1%
0.9 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 5.7% · Q4 7.5% · 4Q avg 5.0% · 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 · 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 | 5.5% |
5.5%
About the same
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 6.9% · Q4 9.7% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.4% |
25.3%
20.9 pts better
|
19.6%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 9.7% · Q4 6.2% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
25.0%
14.6 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.1% · Q3 8.3% · Q4 10.7% · 4Q avg 10.4% · 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 need for help with daily activities has increased | 19.4% |
19.8%
0.4 pts better
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.1% · Q3 17.9% · Q4 32.3% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.4%
0.2 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
2.6%
4 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.2% · Q3 3.0% · Q4 5.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.4% |
18.1%
6.7 pts better
|
19.8%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 9.6% · Q3 15.2% · Q4 7.9% · 4Q avg 11.4% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.0%
3.5 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 9.5% · Q3 9.3% · Q4 10.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
66.4%
22.6 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 91.3% · Q3 92.9% · Q4 79.3% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
13.4%
2.1 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.3% · Expected 11.2% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
63.5%
20.4 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.3% |
25.3%
10 pts worse
|
23.9%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.3% · Observed 32.1% · Expected 21.6% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-12
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 2024-06-05
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-03
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2024-08-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-08
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-05-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-05-10
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2019-05-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-05-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-10
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-05-10
Fire Safety
Use approved construction type or materials.
Corrected 2019-05-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-05-10
Inspection history
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Not marked corrected
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Implement a program that monitors antibiotic use.
Not marked corrected
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Not marked corrected
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Not marked corrected
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.
Not marked corrected
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Not marked corrected
Health
Ensure that residents are free from significant medication errors.
Not marked corrected
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Not marked corrected
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Not marked corrected
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Not marked corrected
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.
Not marked corrected
Health
Provide or get specialized rehabilitative services as required for a resident.
Not marked corrected
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-09
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-31
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-05-21
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-28
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-21
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-19
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-01
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-01-01
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 2023-01-01
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-01
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-01
Health
Post nurse staffing information every day.
Corrected 2022-11-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-05-03
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-05-03
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-03
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-05-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-05-03
Health
Provide activities to meet all resident's needs.
Corrected 2019-05-03
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-05-03
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Nearby options
Kirkwood, MO
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Saint Louis, MO
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
Saint Louis, MO
1-star overall rating with 1-star inspections with $119,588 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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