Cycle 1
Health 2024-08-01 · Fire 2024-08-01
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chesterfield, MO
Surrey Place St Lukes Hospital Skilled Nursing
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
14701 Olive Blvd, Chesterfield, MO
(314) 542-3300
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
51
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-30
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
Hours and turnover
RN hours / resident day
1.84
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.40
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
3.00
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
1.09
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.87
CMS adjusted RN staffing hours
Adjusted total hours
5.49
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,694
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.64% · Performance 24.35% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.26
Baseline 6.13% · Performance 6.86% · Measure score 3.26 · Achievement 3.26 · Improvement 0
Total nurse turnover
0.73
Baseline 29.17% · Performance 60.71% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Adjusted total nurse staffing
5.15
Baseline 4.79 hours · Performance 4.54 hours · Measure score 5.15 · Achievement 5.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 506 · Observed rate 9.88% · Lower 95% interval 8.66% |
| Discharge to community | 59.27% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 563 · Observed rate 54.35% · Lower 95% interval 54.94% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.99% |
95.27%
3.7 pts better
|
Numerator 293 · Denominator 296 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 296 |
| Discharge self-care score | 40.31% |
53.69%
13.4 pts worse
|
Numerator 52 · Denominator 129 |
| Discharge mobility score | 54.26% |
50.94%
3.3 pts better
|
Numerator 70 · Denominator 129 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 2 · Denominator 295 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 317 · Observed rate 6.31% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 2.33% |
8.2%
5.9 pts worse
|
Numerator 4 · Denominator 172 |
| Staff flu vaccination coverage | 80.85% |
42%
38.8 pts better
|
Numerator 190 · Denominator 235 |
| Discharge function score | 47.29% |
56.45%
9.2 pts worse
|
Numerator 61 · Denominator 129 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 116 · Denominator 116 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 153 · Denominator 153 |
| Resident COVID-19 vaccinations up to date | 20.27% |
25.2%
4.9 pts worse
|
Numerator 30 · Denominator 148 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.8%
15.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| 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 | 15.8% |
5.5%
10.3 pts worse
|
5.4%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
25.3%
2.2 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
25.0%
4.4 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · 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 | 2.9% |
19.8%
16.9 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.6% |
1.4%
5.2 pts worse
|
1.0%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.8% |
18.1%
15.3 pts better
|
19.8%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.0%
6.4 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
66.4%
33 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.8% · Q3 98.8% · Q4 99.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
13.4%
1.5 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.9% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
2.2%
2 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
63.5%
34 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
25.3%
2.2 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 28.9% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-21 · Fire 2022-12-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-08-22 · Fire 2019-08-22
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-08-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-06
E · Potential for more than minimal harm
2024-08-01
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 2024-09-06
E · Potential for more than minimal harm
2024-08-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2024-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-08-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2022-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-11
E · Potential for more than minimal harm
2022-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-10
D · Potential for more than minimal harm
2019-08-22
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2019-08-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-02
F · Potential for more than minimal harm
2024-08-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-06
F · Potential for more than minimal harm
2024-08-01
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 2024-09-06
F · Potential for more than minimal harm
2024-08-01
F838 · Administration Deficiencies
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.
Corrected 2024-09-06
E · Potential for more than minimal harm
2024-08-01
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 2024-09-06
E · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-08-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-02
D · Potential for more than minimal harm
2022-12-21
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 2023-02-03
E · Potential for more than minimal harm
2019-08-22
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2019-08-22
D · Potential for more than minimal harm
2019-08-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-08-22
D · Potential for more than minimal harm
2019-08-22
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 2019-09-30
Penalties and ownership
What sits behind the stars
Ownership
St Lukes Episcopal-Presbyterian Hospital
5% Or Greater Direct Ownership Interest · Organization
Bagnall, Andrew
Operational/Managerial Control · Individual
Bagnall, Andrew
Corporate Officer · Individual
Boesch, Jeffrey
Operational/Managerial Control · Individual
Boesch, Jeffrey
Corporate Director · Individual
Eaker, Norman
Corporate Director · Individual
Edwards, Jason
Corporate Officer · Individual
Franklin, Susan
Operational/Managerial Control · Individual
Franklin, Susan
Corporate Director · Individual
Glotzbach, Edward
Corporate Officer · Individual
Ivie, Gina
Operational/Managerial Control · Individual
Ivie, Gina
Corporate Director · Individual
Maritz, Cynthia
Corporate Director · Individual
Price, David
Corporate Officer · Individual
Snowden, James
Corporate Officer · Individual
St Lukes Episcopal-Presbyterian Hospital
Operational/Managerial Control · Organization
Stegmann, Daniel
Corporate Officer · Individual
Vitiello, Jonathan
Operational/Managerial Control · Individual
Vitiello, Jonathan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Westchester House, The
Chesterfield, MO
2-star overall rating with 2-star inspections with $83,824 in total fines with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Friendship Village Chesterfield
Chesterfield, MO
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Delmar Gardens Of Chesterfield
Chesterfield, MO
3-star overall rating with 3-star inspections with $17,160 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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