Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethesda Dilworth during CMS and state inspections, most recent first.
The facility failed to maintain accurate controlled substance records when required shift-change narcotic counts were not completed and documentation for a resident’s oxycodone-acetaminophen was inaccurate. A resident with multiple chronic conditions had an order for scheduled oxycodone-acetaminophen, and a CMT removed and administered a dose without signing it out before administration. Later, the CMT documented the dose based on a prior quantity of six pills, resulting in a recorded balance of five, while only four pills were actually present in the card. The CMT reported arriving late and not completing the narcotic count, and an LPN acknowledged assuming, but not verifying, that counts had been done, contrary to facility policy requiring beginning- and end-of-shift counts and immediate documentation of narcotic removal.
Failure to provide evening and weekend resident activities: The facility’s activity calendars showed no evening programming and little to no weekend offerings, and residents reported they were not offered activities or informed about church services. A resident with mild cognitive impairment, a resident with stroke and altered mental status, and a resident with intact cognition all expressed interest in BINGO, card games, church services, or more stimulating activities, but said those activities were not made available to them. In a group interview, alert and oriented residents said they were bored on weekends and wanted more activities; activities staff said CNAs were responsible for weekend offerings and could forget when busy with care.
Failure to Process Resident and Family Grievances: A cognitively intact resident with mobility limitations, falls, and multiple medical diagnoses had the resident's family member raise numerous nursing care concerns, including fall hazards, pain meds, delayed toileting, lack of follow-up after a fall, and possible retaliation. The SW documented the complaints but did not complete a formal grievance form, the NM did not address all of the concerns, and the family member said no one from management followed up or responded.
A resident with dementia, COPD, depression, anxiety, and malnutrition had hospice services in place, but the significant change MDS did not code hospice care and marked that the resident did not have a condition likely to result in a life expectancy of less than six months. The DON said the MDS should have been coded accurately to reflect the resident's hospice status and prognosis.
Failure to provide needed ADL and grooming care for two residents. One resident with anxiety and heart failure had long nails with dark matter and dry, peeling feet, while the other resident with major depressive disorder, schizophrenia, and epilepsy had dirty hands, long jagged nails, oily hair, and chin hair. Care plans called for assistance with hygiene, grooming, bathing, and nail care, but observations and shower records showed the care was not consistently provided.
The facility did not complete required wound assessments, failed to document wound characteristics, and did not follow its own policies for wound photography and physician notification for multiple residents. One resident's pressure ulcer worsened, leading to sepsis and emergency surgery, and treatment orders were not followed for two residents.
The facility did not notify physicians or resident representatives when three residents developed new or worsening pressure ulcers. Despite facility policy requiring notification and documentation, staff failed to inform the appropriate parties or record these notifications in the medical record. Interviews confirmed inconsistent notification practices, and wound care orders were sometimes entered without prior physician contact.
A resident with multiple complex medical conditions and a history of falls was discharged home alone without necessary home health care services or wound care education. The facility did not involve the resident, family, or IDT in discharge planning, failed to document evaluation of discharge needs, and did not discuss or document safer discharge options, resulting in a lack of a comprehensive, person-centered discharge plan.
A resident with multiple comorbidities and a chronic coccygeal wound did not receive pressure ulcer treatments as ordered, and the physician was not notified when the wound developed drainage and a foul odor. The resident was discharged home alone without home health RN services or wound care instructions, and there was no documentation of appropriate wound care or education prior to discharge.
The facility failed to provide care consistent with professional standards for residents with PICC lines. A resident did not receive antibiotics for two days due to a lack of orders, and another resident's PICC line was not properly maintained. The admitting nurse did not verify the purpose of the PICC lines or obtain necessary orders, leading to deficiencies in care.
A resident with moderate cognitive impairment and mobility assistance needs was injured during a transfer when staff deviated from the care plan due to a dead battery in the sit-to-stand lift. The staff performed a two-person assist transfer, resulting in the resident's foot being caught under the bed and causing a tibial plateau fracture. The incident was not immediately reported, and the injury was discovered after the resident complained of pain.
A resident with moderate cognitive impairment and requiring substantial assistance was improperly transferred by two CNAs when a sit-to-stand lift's battery failed. This resulted in a tibial plateau fracture. The incident was not reported to DHSS as required by the facility's policy, as the Administrator believed it was a witnessed event.
A resident was discharged without an appropriate immediate discharge letter, which lacked essential information such as the effective date of discharge, the specific location of transfer, and details on how to appeal. The resident exhibited aggressive behavior after a medication change, leading to a psychiatric evaluation and transport to a hospital. The facility's discharge form was incomplete, and the Administrator was unaware of the correct Ombudsman's office address.
Failure to Maintain Accurate Controlled Substance Counts and Documentation
Penalty
Summary
The facility failed to maintain accurate records for controlled substances when shift-change narcotic counts were not completed and a narcotic count sheet for one resident was inaccurate. The facility’s policy required all controlled substances to be immediately added to the controlled substance log upon delivery, and required incoming and outgoing nurses or CMTs to count all Schedule II–V controlled substances at the beginning and end of each shift, documenting verification on the controlled substance log. The policy also required immediate reporting and investigation of any missing medications or discrepancies. For Resident #7, who had diagnoses including rheumatoid arthritis, chronic kidney disease, heart failure, low back pain, and diabetes, there was an active order for oxycodone-acetaminophen 10-325 mg to be given four times daily. During observation, a CMT opened the narcotic box, removed one oxycodone-acetaminophen tablet for the resident, and verified that four pills remained in the card. The CMT administered the medication but did not sign it out of the controlled substance book prior to administration, contrary to the facility’s expectations that narcotics be signed out immediately upon removal. When the CMT later went to sign out the dose, the controlled substance sheet showed a previous quantity of six pills, with one signed out for a total of five, while the actual card contained only four pills. The CMT reported that he/she had arrived late and the narcotic counts were not done at the start of the shift. The LPN on duty stated that counts should be done at the beginning and end of each shift but had assumed, without verifying, that the counts were completed. The DON and Administrator both stated they expected staff to complete shift-change counts and to sign out narcotics immediately upon removal, but these processes were not followed in this instance, resulting in an inaccurate narcotic record and inability to reconcile the controlled substance count.
Failure to Provide Evening and Weekend Resident Activities
Penalty
Summary
The facility failed to ensure ongoing resident-centered therapeutic activities were provided in the evenings and on weekends, and failed to ensure activities were offered to all residents who wished to attend. The Garden Terrace activity calendar for June 2025 showed no activities after 2:30 P.M. Monday through Friday, Saturday only had Catholic Mass at 10:30 A.M., and Sunday had no activities. The July 2025 calendar showed no activities after 3:00 P.M. Monday through Friday, Saturday again had Catholic Mass at 10:30 A.M., and Sunday had no activities except a non-denominational church service on 7/20/25 at 2:00 P.M. Resident #140 had an activities evaluation listing interests in BINGO, card games, hand crafts, sewing, and social conversations, and the MDS noted mild cognitive impairment, no behaviors, and that favorite activities and religious services were very important. The resident said he/she had been admitted about a month earlier for rehab, was interested in activities, but was never offered any activities outside of PT. The resident also said he/she was not offered activities over the weekend and did not know about the church service; on 7/21/25, BINGO was observed in the activity room while the resident was in the room watching TV and said he/she did not know BINGO was occurring and would have attended. Resident #155’s record showed diagnoses including stroke, osteoarthritis, high blood pressure, and altered mental status, and the activities evaluation listed interests in BINGO, card games, painting, low impact exercise, books, and church services. The resident said he/she enjoyed bingo, card games, and church services, but had not been offered activities and was not aware of weekend church services. Resident #99 had diagnoses including high blood pressure, bipolar disorder, and COPD with intact cognition, and told activities staff the facility lacked mentally stimulating activities and did not provide math- and science-based activities the resident preferred. In a group interview, six alert and oriented residents said activities were not offered during weekends or evenings and that they wanted more activities. Activities staff said they worked Monday through Friday from 8:00 A.M. to 4:00 P.M., one staff worked weekends, CNAs were responsible for offering weekend activities, and residents had expressed concern about the lack of weekend activities; the Administrator and DON stated residents should be offered activities and there should be ongoing activities on weekends and evenings.
Failure to Process Resident and Family Grievances
Penalty
Summary
The facility failed to follow its grievance policy and procedure for a resident and family member to voice grievances and for the facility to make prompt efforts to resolve those grievances. The policy stated that grievances could be verbal or written, had to be tracked to conclusion by the Grievance Official, and required prompt investigation and written decisions. The Grievance Official was identified as the Administrator or designee, and all management staff were responsible for understanding and enforcing the policy. Resident #9 was cognitively intact, used a wheelchair and walker, and required staff assistance for toileting, hygiene, bathing, dressing, transfers, and walking. The resident also had diagnoses including UTI, arthritis, malnutrition, tremors, vertigo, repeated falls, age-related physical debility, difficulty walking, cognitive communication deficit, and dysphagia. Social service documentation recorded multiple concerns from the resident and family member about nursing care, including water, a grape, and a smashed cracker on the floor creating a fall hazard, the resident waiting in a brief for a long time and falling while trying to change it independently, not receiving pain medication, fluctuating mental status, lack of follow-up after a recent fall, concern that staff would retaliate because the family member spoke up, staff not speaking with or greeting the family member, reluctance to report issues, the resident being kept in bed for days, staff refusing to let the resident get up and walk, a sarcastic comment when a fall sign was placed in the room, crumbs being thrown away that were actually a pill and a half of pain medication, and the resident not seeing a doctor or receiving an x-ray after the fall. During interview, the social worker said the family member voiced concerns related to nursing care, and the social worker copied the note into a Word document, printed it, and handed it to the nurse manager, but did not complete an official grievance form. The social worker expected the nurse manager to follow up because the issues were nursing-care related and did not know who the Grievance Official was. The nurse manager said he or she was not sure whether a list was provided, could not locate it, and only knew about the request for an x-ray after the fall. The nurse manager did not fill out a grievance form or address the other concerns in the social worker's notes. The family member stated he or she told the social worker all complaints about the resident's nursing care, was asked whether an official complaint should be filed, said yes, and never heard back from the facility. The clinical services director stated the complaints were not placed on a formal grievance form, the resolution relied on the form, and the Administrator was responsible for grievance follow-up and resolution.
MDS Did Not Accurately Reflect Hospice Status
Penalty
Summary
The facility failed to ensure that a resident's MDS accurately reflected the resident's status for hospice care. Resident #147 had diagnoses including dementia, COPD, depression, anxiety, and malnutrition, and the medical record showed an ePOS order for a hospice consult and a hospice election form indicating hospice services began. However, the resident's significant change MDS, with an ARD of [DATE], did not mark hospice care as a special service received while a resident and answered "No" to whether the resident had a condition or chronic disease that may result in life expectancy less than six months. The resident later expired at the facility on [DATE]. During interview, the DON stated she did not complete the MDS but expected it to be coded accurately and to reflect that the resident had a prognosis for a life expectancy of less than six months and received hospice care.
Failure to Provide Needed ADL and Grooming Care
Penalty
Summary
The facility failed to ensure two dependent residents received ADL care. Resident #2 had diagnoses including anxiety and heart failure, was cognitively intact, and required substantial to maximal assistance for bathing and supervision or touch assistance for personal hygiene. Although the care plan stated the resident needed assistance with ADLs and maximum assistance for dressing and grooming/hygiene, survey observations showed long nails with dark matter under them on multiple occasions, along with dry, peeling skin on both feet. The resident stated staff had not cleaned or treated the feet recently. Review of the July 2025 shower sheets showed only one bed bath documented and no other shower sheets provided for the month. Resident #8 had diagnoses including major depressive disorder, schizophrenia, and epilepsy, with moderately impaired cognition and dependence for showering/bathing and substantial to maximal assistance needed for personal hygiene. The care plan directed extensive two-person assistance for transfers, dressing, toileting, grooming, bathing, and bed mobility. Survey observations showed the resident's nails were long and jagged with dark matter under them, the hair was oily and stringy, the hands were dirty with matter and food debris, and a patch of chin hair was present. The resident stated a desire for staff assistance with cleaning hands, washing hair, and removing chin hair. The July 2025 shower sheets showed one bed bath with hair washed and one refusal of a bath or shower.
Failure to Prevent and Manage Pressure Ulcers and Notify Physician
Penalty
Summary
The facility failed to maintain an effective skin management program to prevent the development and worsening of pressure injuries. Specifically, wound assessments were not completed as required for two residents, with missing documentation on wound location, stage, size, characteristics, periwound, and wound edge descriptions. Additionally, the facility did not follow its own policy regarding wound photographs and measurements for three residents. There was also a failure to contact the physician prior to initiating a wound treatment order for one resident, and the required SBAR communication tool was not completed when new or worsening wounds were observed. Notification of the physician and family was not performed for three residents experiencing changes in wound status. One resident's pressure ulcer deteriorated, developing drainage and a foul odor, which ultimately required emergency surgery and resulted in a diagnosis of sepsis. Treatment orders were not followed for two residents, further contributing to the deficiencies. The sample size for the review was four residents, with a facility census of 151 at the time of the survey. The facility's policies outlined clear procedures for wound assessment, documentation, and communication, including weekly wound rounds, use of the Braden Scale for risk assessment, and specific documentation requirements for wound characteristics and interventions. Despite these policies, the facility did not adhere to the established protocols, resulting in delayed or incomplete assessments, lack of timely physician notification, and failure to implement or document appropriate interventions for residents with pressure injuries.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and the resident's representative or family member after residents experienced a change in condition, specifically the development or worsening of pressure ulcers. This deficiency was identified through interviews and record reviews for three out of four sampled residents. The facility's policy requires licensed nurses to report changes in condition, incidents, or injuries to both the physician and the resident's representative or family member, and to document these notifications in the medical record. For one resident with severe cognitive impairment and multiple diagnoses, including acute kidney injury and altered mental status, skin assessments revealed the development of a coccyx pressure ulcer and a blister on the right heel. Despite these findings, there was no documentation of notification to the physician or family regarding these changes. Orders for wound care were entered without prior physician notification, and subsequent wound assessments continued to show no evidence of required notifications, even as the wounds progressed and developed drainage and odor. Another resident with moderate cognitive impairment and diagnoses such as hemiplegia, peripheral vascular disease, and diabetes developed multiple pressure injuries on the buttocks and heels. The medical record showed no documentation of physician or family notification for these wounds. A third resident, who was cognitively intact, also developed a coccyx pressure injury, with no evidence of notification to the physician or family. Staff interviews confirmed inconsistent practices regarding notification responsibilities, with some staff indicating that notifications were not routinely made for new or worsening wounds or changes in treatment orders.
Failure to Develop and Implement Effective Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that addressed the resident's discharge goals, needs, and capacity for discharge. The discharge plan did not involve the resident, family, or the interdisciplinary team (IDT) in a meaningful way, nor did it include interventions to ensure a smooth and safe transition to the post-discharge setting. There was no documentation of an evaluation of the resident's discharge needs, nor evidence that the results of any such evaluation were discussed with the resident or family and incorporated into the discharge plan, which is required as part of the comprehensive care plan. The facility did not document discussions with the resident or family about the implications or risks of being discharged to a location that was not equipped to meet the resident's needs. There was no record of presenting or discussing other, more suitable discharge options, nor documentation that the resident refused those options. Additionally, the facility did not determine if a referral to Adult Protective Services or another state entity was necessary, despite the resident being discharged to a potentially unsafe environment. Changes in the resident's condition that impacted the discharge plan were not identified, and necessary revisions to interventions were not made. A resident with multiple complex medical conditions, including diabetes, chronic heart failure, atrial fibrillation, chronic kidney disease, and a chronic coccygeal wound, was discharged home alone without required home health care services or education on wound care. The resident required assistance with transfers, ambulation, and activities of daily living, and had a history of falls, including a recent fall at home after a previous discharge. The facility's own policies required comprehensive discharge planning, interdisciplinary involvement, and documentation, none of which were adequately followed in this case.
Failure to Provide Ordered Pressure Ulcer Care and Discharge Planning
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with its own policies and physician orders for one resident. Specifically, the facility did not administer pressure ulcer treatments as ordered and did not notify the physician when the resident's coccyx/sacral wound developed drainage and a foul odor shortly before discharge. The resident was ultimately discharged to home without home health registered nursing care services and without education or instructions on how to care for the wound. The resident involved had multiple significant medical diagnoses, including diabetes mellitus, chronic congestive heart failure, permanent atrial fibrillation, atherosclerotic heart disease, chronic kidney disease, and peripheral vascular disease. Upon admission, the resident was assessed as having a moderate risk for pressure ulcers, with a Braden score of 14, and required partial to moderate assistance with mobility and transfers. The resident's care plan included preventative skin care measures such as the use of barrier cream, but documentation showed only general references to skin abnormalities and did not provide detailed wound assessments or evidence of consistent wound care interventions. Despite the presence of a chronic coccygeal wound and a physician's order for hydrophilic wound dressing, the facility did not document that wound care was provided as ordered. Additionally, when the wound developed drainage and a foul odor, there was no documentation that the physician was notified or that the care plan was updated. The resident was discharged home alone, without arrangements for skilled nursing follow-up or wound care education, contrary to facility policy and standard practice for wound management.
Deficiencies in PICC Line Management and Antibiotic Administration
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards, particularly concerning the management of peripherally inserted central catheter (PICC) lines. A resident admitted from the hospital with a PICC line did not have orders for PICC line maintenance or antibiotic administration, resulting in a two-day lapse in receiving necessary antibiotics for a bacterial infection. The staff did not verify the purpose of the PICC line or ensure continuity of care from the hospital, leading to a delay in treatment. Another resident was admitted with a PICC line for antibiotic treatment due to a kidney infection and osteomyelitis. However, there were no orders for PICC line maintenance or dressing changes. The resident's PICC line dressing was undated and appeared compromised, indicating a lack of proper care and maintenance. The staff failed to adhere to the facility's policy requiring orders for dressing changes and maintenance for all IVs and PICC lines. Interviews with the Director of Nursing and Registered Nurse revealed that the admitting nurse is responsible for verifying the purpose of the PICC line and obtaining necessary orders. Despite this, the facility did not ensure that the admitting nurse followed through with these responsibilities, resulting in deficiencies in care for residents with PICC lines. The facility's failure to maintain professional standards in managing PICC lines and ensuring continuity of care from the hospital led to these deficiencies.
Inadequate Supervision and Transfer Procedure Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow proper procedures for a resident who required assistance with transfers and mobility. The incident occurred when the resident, who had moderate cognitive impairment and required substantial assistance, was transferred to bed without the use of a sit-to-stand lift due to a dead battery. Despite the resident's insistence on being put to bed, the staff performed a two-person assist transfer, during which the resident's right foot was caught under the bed, resulting in a comminuted tibial plateau fracture. The facility's policy required the use of mechanical lifts for safe transfers, and the resident's care plan specified the need for a stand-up lift with two-person assistance. However, the staff deviated from this plan due to the lift's battery issue and the resident's insistence. The staff did not seek an alternative lift or battery from another floor, as suggested by the facility's Director of Nursing (DON). The incident was not immediately reported to the nurse, and the resident's injury was only discovered after the resident complained of pain and was subsequently sent to the emergency room for evaluation. Interviews with the staff involved revealed a lack of communication and adherence to the facility's policies. The Certified Nurse Assistants (CNAs) involved did not report the incident or the resident's pain to the Licensed Practical Nurse (LPN) on duty. The LPN and Staffing Coordinator were unaware of the injury until the resident was seen with a knee immobilizer after returning from the hospital. The facility's investigation highlighted the failure to follow the mechanical lift policy and the lack of proper assessment and reporting of the resident's condition.
Failure to Report Injury from Improper Transfer
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy by not reporting an incident involving a resident and two staff members in a timely manner. The incident occurred when the staff performed an improper transfer of the resident, resulting in a comminuted tibial plateau fracture. The facility's policy requires immediate reporting of such incidents, especially those resulting in serious bodily injury, to the appropriate state agency. However, there was no documentation indicating that the Department of Health and Senior Services (DHSS) was notified of the incident or injury. The resident involved had moderate cognitive impairment and required substantial to maximal assistance for transfers, as indicated in their care plan. The care plan specified the use of a stand-up lift with two-person assistance for transfers. On the day of the incident, the sit-to-stand lift's battery was not charged, and the resident, who was upset about waiting, was transferred manually by two CNAs. During the transfer, the resident's leg got caught, resulting in a fracture. The resident reported pain immediately after the transfer, but the staff did not recognize the severity of the injury at that time. Interviews with the staff involved revealed that the CNAs attempted to charge the lift's battery but proceeded with a manual transfer when it did not work. The resident expressed discomfort during the transfer, but the CNAs did not report the incident to the nurse immediately. The LPN was informed of the manual transfer but not of the injury. The facility's Administrator and DON acknowledged the injury but did not report it to DHSS, as they believed the incident was witnessed and not an unknown injury.
Failure to Provide Appropriate Immediate Discharge Letter
Penalty
Summary
The facility failed to provide an appropriate immediate discharge letter to a resident, which did not include the effective date of discharge, the specific location to where the resident was transferred, information on how to obtain an appeal form, assistance in completing the form, and submitting the appeal hearing request. Additionally, the letter did not inform the resident that they could return to the facility if an appeal was filed. The Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The resident, who had diagnoses including unspecified dementia, anxiety, and osteoarthritis, became increasingly agitated and aggressive after the facility physician discontinued their oxycodone prescription. The resident exhibited behaviors such as barricading their door, attempting to throw a chair at staff, and using a sharp object as a weapon. The facility physician ordered a psychiatric evaluation and transport to a psychiatric hospital. The resident was escorted out of the building by police and EMTs and was transported to the hospital. The facility's discharge form used for the resident's immediate discharge was found to be incomplete and did not include necessary information such as the effective date of discharge, the location to which the resident was discharged, and information on how to obtain and submit an appeal form. The Administrator stated that the location was not applicable because the resident was going to the hospital and that the appeal information was not applicable because it was not safe to keep the resident in the facility. The Administrator also did not know that the Ombudsman's office address had changed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove At Kirkwood, The | 1.4 mi | ★★★★★ | 29 | 0 |
| Aberdeen Heights | 2.4 mi | ★★★★★ | 1 | 0 |
| Mary, Queen And Mother Center | 2.8 mi | ★★★★★ | 3 | 0 |
| Lutheran Convalescent Home | 3.3 mi | ★★★★★ | 0 | 0 |
| Fountain Care At Sunset Hills | 3.5 mi | ★★★★★ | 3 | 0 |
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