Cycle 1
Health 2024-11-07 · Fire 2024-11-07
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Webster Groves, MO
Lutheran Convalescent Home
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
723 South Laclede Station Rd, Webster Groves, MO
(314) 968-5570
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
251
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evertrue
Operator or chain grouping
Approved since
1995-01-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 5 overall / 5 health / 5 staffing / 4 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
0.92
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.19
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.06
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.62
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
5.57
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
611
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0204
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.76
Baseline 16.42% · Performance 19.23% · Measure score 4.76 · Achievement 4.76 · Improvement 0
Healthcare-associated infections
10
Baseline 4.19% · Performance 4.76% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
5.23
Baseline 40.72% · Performance 42.29% · Measure score 5.23 · Achievement 5.23 · Improvement 0
Adjusted total nurse staffing
6.63
Baseline 5.21 hours · Performance 4.96 hours · Measure score 6.63 · Achievement 6.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.84% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 7.59% · Lower 95% interval 7.01% |
| Discharge to community | 62.59% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 232 · Observed rate 59.05% · Lower 95% interval 56.58% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 105 |
| Discharge self-care score | 66.28% |
53.69%
12.6 pts better
|
Numerator 57 · Denominator 86 |
| Discharge mobility score | 45.35% |
50.94%
5.6 pts worse
|
Numerator 39 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 3.81% |
2.29%
1.5 pts worse
|
Numerator 4 · Denominator 105 · Adjusted rate 5.12% |
| Healthcare-associated infections requiring hospitalization | 4.77% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 0% · Lower 95% interval 2.32% |
| Staff COVID-19 vaccination coverage | 0.63% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 158 |
| Staff flu vaccination coverage | 95.58% |
42%
53.6 pts better
|
Numerator 173 · Denominator 181 |
| Discharge function score | 72.09% |
56.45%
15.6 pts better
|
Numerator 62 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 9 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
84.8%
9.7 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 91.9% · Q4 88.6% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
90.9%
2.6 pts better
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
4.1%
0.5 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 5.8% · Q4 3.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
14.7%
14.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 9.8% |
5.5%
4.3 pts worse
|
5.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 12.7% · Q3 12.7% · Q4 6.3% · 4Q avg 9.8% |
| 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 15.2% · Q2 14.3% · Q3 12.7% · Q4 12.7% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
25.0%
10.9 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.5% · Q3 17.0% · Q4 15.7% · 4Q avg 14.1% · 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 | 16.9% |
20.3%
3.4 pts better
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
19.8%
10.6 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.3% · Q3 9.7% · Q4 4.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.4%
0.8 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.6% · 4Q avg 0.6% · 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 · Q1 3.5% · Q2 3.4% · Q3 2.3% · Q4 3.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
18.1%
3.9 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 25.8% · Q3 17.6% · Q4 18.4% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.0%
0.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.6% · Q3 5.1% · Q4 3.7% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.2% |
66.4%
6.8 pts better
|
81.7%
8.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 72.5% · Q3 72.1% · Q4 76.9% · 4Q avg 73.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
13.4%
7.9 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.2%
0.4 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.5% |
63.5%
17 pts better
|
79.7%
0.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
25.3%
2.5 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 16.3% · Expected 17.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-13 · Fire 2019-09-13
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
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 2024-12-22
E · Potential for more than minimal harm
2024-11-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-22
E · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-22
E · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-22
E · Potential for more than minimal harm
2024-11-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-22
E · Potential for more than minimal harm
2023-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-15
F · Potential for more than minimal harm
2019-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-09-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-09-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-09-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-22
E · Potential for more than minimal harm
2024-11-07
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 2024-12-22
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
F756 · Pharmacy Service Deficiencies
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 2024-12-22
E · Potential for more than minimal harm
2023-08-10
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 2023-09-15
D · Potential for more than minimal harm
2023-08-10
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 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Senior Services
5% Or Greater Direct Ownership Interest · Organization
Anderson, David
Corporate Director · Individual
Anderson, Garry
Corporate Officer · Individual
Bantle, Julie
Corporate Director · Individual
Brown, Daniel
Corporate Director · Individual
Christell, Roy
Corporate Director · Individual
Cooper Carcagno, Valerie
W-2 Managing Employee · Individual
Drollinger, Diane
Corporate Director · Individual
Dunn, Jeffrey
Corporate Director · Individual
Komlos, John
Corporate Director · Individual
Kuhlmann, Frederick
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Norwine, Lisa
Corporate Director · Individual
Sneed, Chadwick
Corporate Director · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sneed, Chadwick
W-2 Managing Employee · Individual
Sombart, Lisa
Corporate Director · Individual
Strand, Sherri
Corporate Director · Individual
Tice, Paul
Corporate Director · Individual
Toon, Norman
Corporate Director · Individual
Wilson, Angela
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#2
Oak Park Care Center
Saint Louis, MO
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Barnes-Jewish Extended Care
Saint Louis, MO
4-star overall rating with 4-star inspections with 11 recent health deficiencies
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