#2 Nazareth Lane, Saint Louis, MO 63129 · St. Louis County · (314) 487-3950
121 certified beds, about 93 residents a day · Non profit - Corporation · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 265636 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 14, 2025, inspectors cited 17 health deficiencies (the Missouri average is 11.4, the national average 9.2).
Of 49 health citations since October 2020, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $11,928 in the last three years; the largest was $11,928, and the latest is dated March 14, 2025.
Nurses and nurse aides worked 3.69 hours per resident per day, against 3.43 across Missouri and 3.86 nationally. Registered nurses accounted for 0.31 of those hours.
77.4% of nursing staff left within the year CMS measured (Missouri average 56.0%).
CMS links it to Benedictine Health System, an affiliated group of 23 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 49 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate assistance to prevent the risk of accidents by failing to ensure appropriate and safe transfer techniques were used in the care of one resident (Resident #1). The resident had a history of a knee replacement and had hardware surgically inserted into the lower end of the femur (upper bone of the leg). As early as 1/28/26, the resident reported pain to the right leg, and no documentation showed staff assessed the leg at this time. On 2/1/26, staff failed to use the foot pedals on the resident's wheelchair while propelling him/her to breakfast and lunch. This resulted in the resident's legs dragging and caused the resident more discomfort in the right leg. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatments and medications were administered as ordered for two of four sampled residents (Resident #4 and Resident #2). The census was 93. Review of the facility's policy on Physician Services, dated 2019, showed the following:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulations;-Procedure: #8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Review of the facility's policy on Administering Medications, dated 2020, showed the following:-Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider;-Policy: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free from accidents when staff failed to properly secure straps in the facility's van during transportation to an appointment, resulting in one resident flipping backward in their wheelchair (Resident #1). The census 101. The Administrator was notified on 12/16/25 of the past non-compliance. The facility in-serviced staff responsible for providing transportation to residents on proper wheelchair positioning and the facility's policy of transporting one wheelchair-bound resident at time in the medical van. The deficiency was corrected on 12/8/25. Review of the facility's policy on Fleet Safety Program, dated 2021, showed the following:-Purpose: To promote safe operation of vehicles within the facility's community and to satisfy auto insurance underwriting requirements;-Policy: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) received care consistent with professional standards when staff failed to report a large bruise and abrasion to the resident's head immediately, delaying assessment, proper care and required notifications to family and physician. The sample size was three. The census was 88. Review of the facility's Change in Condition policy, dated 10/2/23, showed:-Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider. To inform resident/resident representative and attending provider when a significant change in resident condition occurs;-Policy: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #4) received treatment and care in accordance with acceptable standards of practice when the facility failed to follow physician orders for a Prevena (wound vac, negative pressure wound therapy (NPWT) system used to manage closed surgical incisions) and the resident's wound dehisced (separation of the edges of a surgical wound, either partially or completely, due to failure of proper wound healing). Additionally, the facility failed to administer physician ordered medications and failed to notify the physician and resident representative (RR) that the medications and treatments were not administered. The census was 84. Review of the facility's physician services policy, copyright 2022, showed:-Policy: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when facility staff failed to administer physician ordered medications for three residents (Resident #1, Resident #2 and Resident #6) and failed to notify the physician and resident representative (RR) that the medications were not administered. The facility failed to follow parameters in the physician orders for one resident (Resident #5) and administered medications outside of the parameters and did not notify the physician or RR when medication was administered outside the set parameters. The census was 84. Review of the facility's physician services policy, copyright 2022, showed:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulation;-Procedure: 8. [...]
Inspectors wroteBased on interview and record review, the facility failed to establish a system for records of disposition of all controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) in sufficient detail to enable an accurate reconciliation with the narcotic delivery reconciliation logs and shift to shift count sheets for four carts out of four carts that had controlled substances. This had the potential to affect all residents with controlled substance orders. The census was 84. Review of the facility's Controlled Substances Policy, copyright 2025, showed:-Purpose: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when staff misappropriated $90.00 of the resident's money from his/her personal account and without the resident's consent (Resident #8). The census was 84. Review of the facility's Abuse Prevention Plan policy, copyright 2017, showed: -3. Training of Employees, Contract Staff, and Volunteers: Training will be provided to all new and existing employees, contract employees, and volunteers through orientation and annual training programs related to effective communication, dementia management and abuse prevention, freedom from abuse, neglect, and exploitation. This includes training and orientation to resident needs for agency staff. Nurse's aides are required to have 12 hours of training annually. [...]
Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of four medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 93. Review of the facility's Controlled Substance Storage policy, revised, March, 2017, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, twelve errors occurred, resulting in a 38.71% error rate (Resident #83, Resident #196, Resident #79 and Resident #197). The census was 93. Review of the facility's Administrating Medications policy, revised 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. -Administer medications following the six rights of medication administration; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals (medications that are grown from bacteria or viruses) stored in the medication room refrigerator were being stored at a proper temperature for 1 out of 1 medication rooms observed. The facility failed to have medication storage boxes filled with medication in a secure area. The census was 93. Review of facility's Medication Storage Policy, dated, March, 2017, showed: -Policy: Medication and biologicals are stored safely, securely and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Procedure: [...]
Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges, and failed to provide a written notice of transfer/discharge to one resident (Resident #90) and/or resident representative when the resident was transferred to the hospital. The sample was 21. The census was 93. Review of the facility's Discharge Planning policy, dated 11/28/17, showed: -Purpose: To prepare the resident for and ensure a safe discharge from the facility; -The policy did not provide guidance related to notification to the Ombudsman regarding resident transfer and discharges; -The policy did provide guidance related to ensuring residents and/or resident representatives are provided with written notification as soon as practicable following a resident's transfer to the hospital. 1. [...]
Inspectors wroteBased on interview and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for three residents (Residents #90, #195 and #194). The census was 93. Review of the facility's Comprehensive Assessments and Care Planning policy, revised [DATE], showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the Resident Assessment Instrument (RAI) specified by the State; -Policy: --The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to develop a plan of care specific to each resident's needs. Concerns were found in the care plans for three out of 21 sampled residents when the facilty failed to include the presence of side rails (Resident #52), presence of a urinary catheter (Resident #11), and presence of hospice services (Resident #20) in the resident care plans. The facility census was 93. Review of the facility's Comprehensive Assessments and Care Planning Policy, revised 9/27/23, showed: -Purpose: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to meet professional standards of practice when staff held medications for two residents (Residents #79 and #83) with low blood pressure and failed to notify the nurse so the nurse could notify the physician to initiate parameters. Staff failed to ensure medication was available for administration and to administer available medications for one resident (Resident #15), and the facility failed to have a sufficient system in place to track pharmacy refill requests. The sample was 21. The census was 93. Review of the facility's Change in Condition policy, undated, showed; -Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider; [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided for three of 21 sampled residents. The facility failed to ensure one resident had accurate skin assessments, trimmed nails and clean skin (Resident #82). The facility also failed to ensure two residents received facial hair grooming (Residents #65 and #20). The census was 93. Review of the facility's ADL policy, dated 2021, showed: -Policy: residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility; -Implementation: care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to obtain treatment orders for one resident (Resident #195) who had a recent hip surgery. The sample size was 21. The census was 93. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 9/1/18, showed: -Purpose: Maintaining intact skin is integral to the resident's health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur; -Procedure: Skin is observed daily with care; Documentation of the skin impairment is completed in the medical record; Notify the attending provider and the attending provider may provide additional orders. Review of Resident #195's, face sheet, undated, showed: -An admission date of 3/6/25; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #82) had urinary catheter (tube that drains the urine from the bladder) orders and failed to flush one resident's urinary catheter who had a history of hematuria (blood in the urine) (Resident #1). The sample was 21. The census was 93. Review of the facility's Prevention of Catheter-Associated Urinary Tract Infections policy, undated, showed when a resident is admitted to the facility with a catheter in place, a thorough physical assessment, as well as history review will be completed. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/17/25, showed: -Cognitively intact; -The resident has an indwelling urinary catheter; [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident had all the required physician's orders and documentation of oxygen usage (Resident #16), and failed to ensure one resident's discontinued physician's orders related to oxygen usage were reinstated after a hospital stay (Resident #2). The sample was 21. The census was 93. Review of the facility's oxygen therapy policy, dated 2017, showed: -Policy: Residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan; -Procedure: Obtain physician orders for specifics regarding administration. Administration of the oxygen therapy is completed by nursing associates. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management for three of 21 sampled residents who experienced pain, consistent with professional standards of practice (Residents #195, #1, and #7). The census was 93. Review of the facility's Pain Management policy, dated 2022, showed: -Policy: Benedictine considers pain that impacts the function or quality of life of our residents a significant concern and evaluation will be ongoing. The Benedictine interdisciplinary team will strive to manage pain in residents experiencing mild to debilitating pain to the point where functionality and quality of life can be increased. Benedictine clinicians will be aware of the unique needs and circumstances of residents from different age groups, ethnic and cultural backgrounds. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and failed to ensure residents using bed/side rails had adequate and on-going assessments to determine the side rails were appropriate and safe for use, obtained informed consent from the resident and/or responsible party, obtained physician orders per facility policy, and included the use of siderails in the resident's care plan. The facility identified 34 residents with side rails in use. Two of 21 sampled residents (Residents #16 and #52) had side rails but were not properly assessed for side rails. The census was 93. Review of the facility's Chemical and Physical Restraints Policy, revised 8/31/23, showed: -The resident has the right to be free from any physical or chemical restraints not required to treat the resident's condition. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident (Resident #194) was free of significant medication error by not obtaining the residents prescribed antibiotic and antiviral medication in a timely manner. The sample size was 21. The census was 93. Review of the facility's Administrating Medications policy, revised, 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider in if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to adequately develop and implement infection control practices to prevent the spread of infection caused by transmission-based conditions. The facility also failed to adequately follow its Enhanced Barrier Precautions (EBP) Policy (Residents #194 and #7). This failure had the potential to affect all residents and staff in the facility. The census was 93. Review of the facility's Enhanced Barrier Precautions policy, revised 4/1/24, showed: -Enhanced Barrier Precautions is a strategy in nursing homes to decrease transmission of CDC-targeted and other epidemiologically important multidrug-resistant organisms (MDROs, an infection resistant to common treatment therapies); -EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDROs; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for two residents (Residents #16 and #52). The facility identified 34 residents with side rails in use. The census was 93. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; [...]
Inspectors wroteBased on interview and record review, the facility failed to explicitly inform the resident or their representative of their right not to sign an arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) as a condition of admission, or as a requirement to continue to receive care at the facility, and to have the residents properly indicate their choices on signed admission agreements for two of three residents sampled for review of arbitration agreements (Residents #1 and #52). The census was 93. Review of the facility's admission packet, showed, dated September 2019, showed: -Arbitration: --A. By selecting I agree to arbitrate and initialing below, you agree to the following: -1. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure daily weights were obtained as ordered (Resident #1). The resident sample was 6. The census was 87. Review of Resident #1's hospital discharge/transfer sheet, dated 5/29/24, showed: -Weigh daily; -Contact the physician if there is a weight gain of 3 pounds or more in a day or 5 pounds or more in two days. Review of Resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 6/4/24, showed: -admission date 5/29/24; -Cognitively intact; -Diagnoses included congestive heart failure (the heart does not pump enough blood); -Weight loss of 5% or more in last month or a weight loss of 10% or more in last six months; -On a physician's weight loss program -Weight 160 pounds. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #96) received appropriate supervision for wandering. The resident was admitted to the facility from the hospital on 7/26/23. The resident's hospital records showed the resident was found on 7/19/23, by a bystander, confused and wandering around his/her apartment complex. The resident was unable to tell Emergency Medical Staff (EMS) where he/she lived. The resident's family informed hospital staff the resident had been having progressive, worsening mental functioning and forgetfulness. The facility failed to ensure admission staff thoroughly read the hospital records and put elopement/wandering interventions in place upon the resident's admission. On 8/4/23 around 11:40 A.M., the Health Information Director (HID) opened the door and allowed the resident to leave unsupervised. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist reports any irregularities to the attending physician and the facility's medical director and director of nursing, and ensure these reports were acted upon. In addition, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident for four of seven residents investigated for the monthly medication regimen review (Residents #65, #68, #48, and #8). This had the potential to affect all residents with irregularities identified during the monthly medication review. The census was 86. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two out of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #191 and #101). The facility census was 86. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were complete, accurate, reviewed, and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for five of 18 sampled residents (Residents #82, #83, #44, # 48, and #68). The census was 86. 1. Review of Resident #82's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/13/23, showed: -admitted [DATE]; -Cognitively intact; -Rolling from left to right, moving from sitting to lying and lying to sitting: Substantial/maximal assistance needed; -Diagnoses include kidney disease and diabetes; -Care Area Assessment Summary (CAAS) triggered and was identified as care planned by the facility for: [...]
Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three controlled substance shift change count sheets reviewed. The census was 86. Review of the facility's Consultant Pharmacist Services Provider Requirements policy, revised August 2014, showed: -The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility; -Establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. 1. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure orders for psychotropic medications are limited to 14 days, except when the prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days, has documented the rationale in the resident's medical record, and indicated the duration of the as needed order. The facility failed to ensure a gradual dose reduction was attempted or documented as contraindicated for residents who receive psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted and documented prior to administration of a psychotropic medication, for three of five residents investigated for unnecessary psychotropic medications (Residents #65, #8, and #68). The census was 86. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals are labeled and stored in accordance with currently accepted practices. These practices affected two of four medication carts reviewed and one out of two medications rooms reviewed. The census was 86. Review of the facility's Medication Storage in the Facility policy, revised on 2014, showed: -Policy: -Medications and biologicals (vaccines) are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Procedure (includes): -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide eating assistance to one resident (Resident #44) for two of two observed meals. The resident was observed feeding himself/herself with his/her fingers. Staff did not provide assistance. The sample was 18. The census was 86. Review of the undated Activity of Daily Living (ADL) policy, showed: -Purpose: To provide residents with care, treatment and services appropriate to maintain or improve the ability to carry out ADLs; -Policy: Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene; -Implementation: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #92) was free from significant medication error when staff failed to ensure the resident's ordered breathing treatment was delivered timely. The resident was admitted to the facility from the hospital with respiratory failure and Covid-19. The resident did not receive the ordered breathing treatments all days of the stay, from 9/29/23 through 10/4/23. The sample size was 37. The census was 86. Review of the Verbal and Telephone Order policy, showed: -Purpose: To ensure timely and efficient verbal and telephone orders from the provider; -Policy: Verbal and telephone orders are obtained in a situation when the provider is unable to write or sign the order at the time of entry and are transcribed; -Procedure: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections for one resident observed during personal care and transfer when staff failed to change gloves, sanitize hands, and sanitize shared medical equipment using acceptable standards of practice (Resident #82). The census was 86. Review of the facility's Using a Mechanical Lifting Machine policy, dated July 2017, showed lift care: -Disinfect lifting surfaces; -Wipe with a clean towel until dry. Review of the facility's Hand Hygiene policy, dated June 2017, showed: -Infection prevention begins with the basic hand hygiene. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to make available the results of the most recent annual survey and any abbreviated survey completed since the most recent annual survey, in a place readily accessible to residents, family members and legal representatives of residents. The census was 86. Observation 10/23/23 at 1:15 P.M., showed the facility's survey results binder labeled and located in the activity room. Review of the facility's survey results binder, showed: -It included the statement of deficiencies (SOD) for the most recent health annual survey, dated 10/9/20. No plan of correction (POC) was included; -No Life Safety Code SOD or POC for the annual survey completed on 10/9/20; -No SOD or POC for the abbreviated survey and infection control survey, completed on 5/10/21; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to follow their abuse and neglect policy and complete a prompt and thorough investigation for an allegation of abuse, for three of 19 sampled residents (Residents #42, #3 and #13). The census was 81. Review of the facility's Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. Concerns, incidents and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrences; -Abuse prevention plans. [...]
Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for controlled substances, for five of six medication carts. The census was 81. 1. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for [NAME] Hall, showed the following: -No signature by the on-coming nurse, total of five shifts; -No signature by the off-going nurse, total of five shifts; -Total narcotic drug cards not documented as counted, a total of five shifts; -Total narcotic drug cards not legible counted, a total of one shift. 2. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for FontBonne Hall, showed the following: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were reviewed and the facility failed to notify the physician, medical director, and director of nursing of irregularities, for two of 9 residents sampled for medication review (Residents #57 and #29). In addition, the facility's policy failed to include time frames for the different steps in the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident. The sample was 19. The census was 81. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/1/07, showed: -The facility should ensure that facility physicians/prescribers are provided with copies of MMRs; [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff labeled drugs and biologicals per acceptable standards of practice when staff failed to date insulin flexpens (prefilled injectable insulin) once they were opened, ensure legible dates and resident names were on the label and failed to discard opened insulin flexpens for residents discharged from the facility, for two of four medication carts checked. The census was 81. 1. Observation on 10/6/20 at 7:56 A.M., of the nurse's medication cart, front hall of [NAME], showed the following: -One Novolog (fast acting) insulin flexpen opened without a date written when opened. Licensed Practical Nurse (LPN) B said the resident was discharged ; -One Lantus (long acting) insulin flexpen opened without a date written when opened; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure acceptable infection control standards were used when staff failed to clean/disinfect a gait belt (a device used to transfer residents from one position to another) that is used on multiple residents, before or after use for one resident (Resident #66) and failed to clean/disinfect the sit to stand lift (mechanical lift) that is used on multiple residents, before/after use for one resident (Resident #57). In addition, staff failed to wash or sanitize their hands after removing gloves while providing personal care to one resident (Resident #69) and failed to cover clean laundry that was hanging in the hall, five out of five days observed. The resident sample was 19. The census was 81. Review of the facility's Cleaning, Disinfection and Sterilization-Overview Policy, dated 2017, showed: -Purpose: [...]
Inspectors wroteBased on interview and record review, the facility failed to report alleged violations of abuse to the Department of Health and Senior Services (DHSS) immediately, but not later than 2 hours after the allegation was made, after two allegations of abuse. This affected one of 19 sampled residents (Resident #42). The facility census was 81. Review of the facility Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice when staff failed documented the fluid and meal intake of two residents as indicated in their plan of care (Residents #27 and #179). In addition, the facility failed to ensure daily weights were obtained as ordered (Resident #179). The resident sample at 19. The census was 81. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 8/5/20, showed: -Severe cognitive impairment; -Required supervision with meals; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months, marked yes. Not on physician prescribed weight loss. Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnosis included: [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to shave and provide nail care for two residents who were dependent on staff for care needs (Residents #23 and #29). The sample was 19. The census was 81. Review of the facility policies, showed; -No policy for fingernail care, shaving care or oral; -A staff skill competency check form for fingernail care, oral care and shaving with electric razor (dated 2009). The competency check forms did not indicate how often to provided nail care or shaving care or when this care would be indicated as needed. 1. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received Restorative Therapy (RT) as indicated for three resident's (Residents #23, #30 and #22) sampled who had orders for RT. The sample was 19. Census was 81. Review of the facilities Restorative Program policy, dated 2017, showed: -Purpose: To ensure residents are comprehensively assessed/reassessed for restorative needs; -Policy: To provide a basic outline and guidance for implementation and tracking of restorative programs established so that each resident can attain and maintain highest physical, mental and psychosocial well-being. Restorative nursing care promotes resident's highest level of independence in each of the following areas: -Activities of Daily Living (ADLs); -Splints/brace; -Range of Motion (ROM); -Ambulation; -Bed Mobility; -Procedure: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents when staff transferred a resident improperly when using a mechanical lift for one of three transfers observed. In addition, staff failed to investigate the cause of a skin tear so interventions could be implemented to prevent further injury for one (Resident #23). The sample size was 19. The census was 81. Review of the facility's policies showed: -No mechanical lift policy; -A staff skill competency form for mechanical lifts, dated 2009 provided. Review of the undated staff skill competency form, showed: -Obtain assistance from experienced team member; -Instruct your assistant to guide resident to chair. Watch that arms, legs and tubing are safe; -Check that the base of the legs for the lift are properly positioned to support resident weight. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thorough assessments, monitoring and ongoing communication with the dialysis center. The facility also failed to obtain a dialysis contract. The facility identified one resident receiving dialysis (Resident #40). The resident sample was 19. The census was 81. Review of the facility's 2017 dialysis (process for removing toxins from the blood for individuals with kidney failure) policy, showed: -Policy: Dialysis is provided via contract with an external agency. Care for residents that requires dialysis will be managed by licensed associates and through communication with a certified dialysis service; -Procedure: Residents are informed of the dialysis services the community can accommodate at the time of admission and dually informed if such services are required for the resident following admission; [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure as needed psychiatric medications were evaluated after 14 days of use for one of seven residents reviewed for unnecessary psychotropic medications (Resident #66). The sample was 19. The census was 81. Review of Resident #66's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/20, showed diagnoses included Alzheimer's disease, heart failure and diabetes. Review of facility's policy for psychotropic medication use, dated 2018, showed: -Psychotropic medications ae given upon a medical provider order; -The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-review; [...]
19 fire safety citations on file: 10 on March 14, 2025, 6 on October 26, 2023, 3 on October 9, 2020.
| Date | Penalty | Amount or length |
|---|---|---|
| March 14, 2025 | Payment Denial | 4 days from June 14, 2025 |
| October 26, 2023 | Fine | $11,928 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Missouri | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.69 | 3.43 | 3.86 |
| Registered nurses | 0.31 | 0.46 | 0.69 |
| All nursing staff on weekends | 3.30 | 3.01 | 3.42 |
| Nurse aides | 2.32 | ||
| Licensed practical nurses | 1.05 | ||
| Nursing staff turnover (share who left in a year) | 77.4% | 56.0% | 45.8% |
| Registered nurse turnover | 85.7% | 47.8% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.84 on weekdays and 3.30 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 45.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.84 in April to June 2025 to 3.69 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.69 | 0.31 | 3.84 | 3.30 | 45.1% | 0 of 90 | 93 |
| Oct to Dec 2025 | 3.74 | 0.26 | 3.87 | 3.39 | 41.2% | 0 of 92 | 93 |
| Jul to Sep 2025 | 3.73 | 0.26 | 3.84 | 3.43 | 42.8% | 0 of 92 | 94 |
| Apr to Jun 2025 | 3.84 | 0.22 | 3.98 | 3.48 | 40.0% | 2 of 91 | 90 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Missouri, Jan to Mar 2026 | 3.34 | 0.40 | 3.50 | 2.93 | 3.9% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Missouri, all employers | |||
| CNAs (nursing assistants) | $18.11 | $17.02 to $20.00 | 34,050 |
| LPNs and LVNs | $29.58 | $27.06 to $33.77 | 14,700 |
| Registered nurses | $39.32 | $36.56 to $47.39 | 76,310 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Missouri | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 38.3 | 18.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.6 | 1.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.9 | 2.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.2 | 4.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 46.0 | 17.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.9 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 22.6 | 23.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 35.1 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.6 | 13.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 2.3 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Nazareth Living Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (57.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
57.6% this home
Better than the national rate
US median of homes 51.5% · Missouri: 41 better, 31 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 249 eligible stays.
14.2% this home
No different from the national rate
US median of homes 10.7% · Missouri: 0 better, 7 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 283 eligible stays.
6.6% this home
No different from the national rate
US median of homes 7.1% · Missouri: 1 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 163 eligible stays.
49.5% this home
Median of homes: Missouri51.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 105 residents counted.
0.7% this home
Median of homes: Missouri0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 142 residents counted.
1.6% this home
Median of homes: Missouri2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 142 residents counted.
100.0% this home
Median of homes: Missouri100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 71 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: NAZARETH LIVING CENTER. CMS links this home to Benedictine Health System, a group of 23 nursing homes averaging 2.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sisters of St. Joseph of Carondelet St. Louis Province | 5% or greater direct ownership interest | Organization | 50% | 07/01/2009 |
| Collins, Julie | Contracted managing employee | Individual | 08/09/2021 | |
| Bruhn, Jennifer | Corporate director | Individual | 07/01/2020 | |
| Deblois, Beverly | Corporate director | Individual | 07/01/2020 | |
| Essig, Leonard | Corporate director | Individual | 06/30/2014 | |
| Hadican, Mary Kay | Corporate director | Individual | 06/30/2014 | |
| Harris, Marie | Corporate director | Individual | 07/01/2015 | |
| Haywood, Michael | Corporate director | Individual | 07/01/2017 | |
| Hogan, Sean | Corporate director | Individual | 07/01/2019 | |
| Ludwig, Robert | Corporate director | Individual | 06/30/2014 | |
| Lutzeier, Fred | Corporate director | Individual | 07/01/2018 | |
| Moore, Elaine | Corporate director | Individual | 10/01/2011 | |
| Rapp, Deborah | Corporate director | Individual | 07/01/2016 | |
| Rymanowski, Kevin | Corporate director | Individual | 01/01/2011 | |
| Bergien, Tricia | Corporate officer | Individual | 08/23/2017 | |
| Benedictine Health System | Operational/managerial control | Organization | 07/01/2009 | |
| Carley, Gerald | Operational/managerial control | Individual | 12/18/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Missouri. NursingHomeClear cannot take or act on complaints.