Cycle 1
Health 2024-10-09 · Fire 2024-10-09
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ballwin, MO
Lutheran Senior Services At Meramec Bluffs
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
50 Meramec Trails Drive, Ballwin, MO
(636) 861-0600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Evertrue
Operator or chain grouping
Approved since
2007-01-01
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
1.39
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.52
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
2.69
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.83
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.47
CMS adjusted RN staffing hours
Adjusted total hours
5.85
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
978
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0165
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.93
Baseline 18.34% · Performance 19.15% · Measure score 4.93 · Achievement 4.93 · Improvement 0
Healthcare-associated infections
7.12
Baseline 7.57% · Performance 5.71% · Measure score 7.12 · Achievement 7.12 · Improvement 6.75
Total nurse turnover
5.95
Baseline 45.75% · Performance 39.34% · Measure score 5.95 · Achievement 5.95 · Improvement 2.56
Adjusted total nurse staffing
6.57
Baseline 9.15 hours · Performance 4.95 hours · Measure score 6.57 · Achievement 6.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.69% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 153 · Observed rate 10.46% · Lower 95% interval 8.23% |
| Discharge to community | 58.52% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 155 · Observed rate 58.06% · Lower 95% interval 52.31% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 88 · Denominator 88 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 88 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 28 · Denominator 74 |
| Discharge mobility score | 25.68% |
50.94%
25.3 pts worse
|
Numerator 19 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 1.14% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 88 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 1.28% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 76 |
| Staff flu vaccination coverage | 90.67% |
42%
48.7 pts better
|
Numerator 68 · Denominator 75 |
| Discharge function score | 43.24% |
56.45%
13.2 pts worse
|
Numerator 32 · Denominator 74 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 53.85% |
25.2%
28.7 pts better
|
Numerator 28 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
84.8%
10.6 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · 4Q avg 95.4% |
| 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 | 1.5% |
4.1%
2.6 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.6% |
14.7%
5.9 pts worse
|
11.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% |
| Percentage of long-stay residents who lose too much weight | 12.2% |
5.5%
6.7 pts worse
|
5.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.4% |
25.3%
22.9 pts better
|
19.6%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
25.0%
22.2 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
19.8%
14.4 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · 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 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.7% |
2.6%
5.1 pts worse
|
1.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
18.1%
4.4 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.0%
1.4 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.4% |
66.4%
10 pts better
|
81.7%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 87.0% · Q3 84.4% · Q4 60.0% · 4Q avg 76.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
13.4%
3.8 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.2% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.2% |
63.5%
9.7 pts better
|
79.7%
6.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.3%
1.6 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 17.8% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-07 · Fire 2022-12-07
1 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2019-06-21 · Fire 2019-06-21
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-12-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-21
E · Potential for more than minimal harm
2022-12-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-12-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-10
E · Potential for more than minimal harm
2022-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-21
F · Potential for more than minimal harm
2019-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-29
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 2026-02-03
D · Potential for more than minimal harm
2025-12-29
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 2026-02-03
D · Potential for more than minimal harm
2024-10-09
F688 · Quality of Life and Care Deficiencies
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 2024-11-08
E · Potential for more than minimal harm
2022-12-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-21
F · Potential for more than minimal harm
2019-06-21
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 2019-08-04
D · Potential for more than minimal harm
2019-06-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-04
D · Potential for more than minimal harm
2019-06-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-04
D · Potential for more than minimal harm
2019-06-21
F690 · Quality of Life and Care Deficiencies
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 2019-08-04
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Senior Services
5% Or Greater Direct Ownership Interest · Organization
Anderson, David
Corporate Officer · Individual
Beumer, Brent
Corporate Director · Individual
Brown, Daniel
Corporate Officer · Individual
Christell, Roy
Corporate Director · Individual
Cooper Carcagno, Valerie
Operational/Managerial Control · Individual
Lin, Walter
Operational/Managerial Control · Individual
Marles, Adam
Corporate Director · Individual
Marles, Adam
Corporate Officer · Individual
Meadows, Megan
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sombart, Lisa
Corporate Director · Individual
Sommer, Christopher
Corporate Director · Individual
Tice, Paul
Corporate Officer · Individual
Toon, Norman
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Manchester Rehab And Healthcare Center
Ballwin, MO
1-star overall rating with 1-star inspections with $239,993 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Big Bend Woods Healthcare Center
Valley Park, MO
1-star overall rating with 2-star inspections with $185,221 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Delmar Gardens On The Green
Chesterfield, MO
3-star overall rating with 3-star inspections with $51,511 in total fines with 13 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
Jump out