Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Country Villa Wellness & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that nursing staff repeatedly failed to administer and/or document physician-ordered medications and treatments for multiple residents, despite facility policies requiring accurate transcription and real-time MAR documentation. Residents with conditions such as diabetes, heart failure, Parkinson’s disease, COPD, seizure disorders, chronic pain, and psychiatric illnesses had numerous blank MAR entries for critical medications including insulin (both sliding-scale and long-acting), anticoagulants, anticonvulsants, antihypertensives, diuretics, psychotropics, Parkinson’s agents, inhalers, antibiotics, vitamins, supplements, and GI medications. At least one resident reported missed pain and diabetes medications and described increased pain and high blood sugars, while resident council minutes reflected broader concerns about untimely and missed medications. The absence of required documentation or explanatory notes for these omitted doses demonstrated a systemic failure to follow professional standards and facility policy for medication administration and recordkeeping.
The facility failed to follow its fall policy and acceptable standards of practice by not performing and documenting required neuro checks after unwitnessed falls for three residents. In each case, a resident was found on the floor after an unwitnessed fall, vital signs and basic assessments were completed, and injuries such as skin tears, bruising, or abrasions were addressed, but there was no documentation of 72-hour neuro monitoring as required for unwitnessed falls. Facility leadership stated they expected nurses to complete head-to-toe assessments, initiate neuro checks for unwitnessed falls or head strikes, and document post-fall monitoring each shift, but chart reviews showed these neuro checks were not done.
Multiple residents experienced unwitnessed falls and an injury during a staff-assisted transfer, and staff did not follow facility policies for post-fall management, family notification, and adherence to transfer orders. After several falls, staff completed incident reports but did not convene or document IDT reviews, did not add or revise care plan interventions to reduce future falls, and in two cases did not notify the resident’s family/responsible party. One resident with severe cognitive impairment sustained a fall with injury and was sent to the hospital without any documented post-fall risk evaluation or new interventions. Another cognitively intact resident, ordered and care planned for a full-body lift transfer with three staff, reported being transferred by only two CNAs with a Hoyer lift, resulting in a skin tear and bruising to the hand and forearm; no incident report, skin assessment, physician or RR notification, or post-incident monitoring was documented, and later observation confirmed that only two staff were performing the Hoyer transfer despite the three-person order.
A resident with a seizure disorder and multiple comorbidities had numerous scheduled doses of Depakote ER, levetiracetam, lacosamide, and lorazepam not documented as administered on the MAR, despite physician orders and a care plan requiring seizure medications to be given as ordered. Facility policies required accurate transcription of orders, timely administration, and immediate documentation on the MAR, but paper MARs showed repeated blank boxes for critical anticonvulsant and lorazepam doses, and PRN lorazepam orders were incompletely documented. An LPN acknowledged relying on the controlled substance count sheet rather than the MAR, stated that nurses were not always signing MARs because workload was too high after CMT roles changed, and admitted not verifying that all anti-seizure medications were being given. A CMT reported that some residents’ MARs were missing from the binder and could not recall to whom this was reported. Another LPN described multiple observed seizures in the dining room without completing a progress note, while hospice staff and the physician reported increased seizure activity that month and linked it to missed seizure medications.
Staff failed to treat a resident with dignity and respect when an LPN recorded and posted a video of a cognitively impaired, hospice resident on social media without written consent, in violation of facility policy. Additionally, staff were observed using personal cell phones in resident areas during mealtime, despite clear policies prohibiting such actions. Leadership acknowledged these expectations, but enforcement and staff education were lacking.
Staff failed to use safe, professional standards during mechanical lift transfers, resulting in injuries to two residents. One resident suffered a severe leg injury requiring hospitalization and surgery after being struck during a transfer, while another experienced multiple incidents of being bumped or struck by lift equipment. Investigations were incomplete, care plans were not updated, and required staff training was not documented, despite residents' repeated complaints of unsafe handling and lack of staff responsiveness.
Widespread Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and treatments were administered and documented in accordance with physician orders and the facility’s own medication administration policies. Facility policies required that all physician orders be complete and accurately transcribed to the MAR/TAR, that medications be administered as prescribed, and that the individual administering the medication document administration directly after giving the dose, including circling and explaining any withheld, refused, or unavailable doses. Resident council minutes documented resident concerns that medications were not being received timely and that doses were being missed. Multiple residents with significant medical conditions had numerous blank entries on their MARs where ordered medications and treatments should have been documented. One cognitively intact resident with diagnoses including heart failure, morbid obesity, anxiety, chronic pain, and hypertension had repeated blank MAR entries for Eliquis, Lasix, potassium chloride, famotidine, ondansetron, gabapentin, Miralax, Tylenol, vitamins, artificial tears, Senna Plus, and a lidocaine patch, among others. This resident reported not receiving medications as ordered and specifically stated that missed gabapentin doses caused increased pain in the feet. Another cognitively intact resident with diabetes, stroke, hemiparesis, and depression had multiple undocumented pre-meal blood glucose checks and corresponding Novolog sliding-scale insulin doses, as well as missed or undocumented doses of long-acting insulin (Tresiba) and metformin, and reported not receiving insulin for several days and having a blood sugar over 200 when it was eventually checked. Additional residents with diabetes, dementia, chronic kidney failure, psychiatric diagnoses, atrial fibrillation, anemia, chronic pain, hypertension, COPD, Parkinson’s disease, seizure disorders, and other chronic conditions also had numerous blank MAR entries for ordered medications. These included missed or undocumented blood glucose checks and insulin doses, anticonvulsants (carbamazepine, Keppra), anticoagulants (Eliquis, aspirin), antihypertensives (metoprolol, carvedilol, amlodipine, hydrochlorothiazide), diuretics (Lasix), psychotropics (mirtazapine, quetiapine, trazodone, duloxetine, buspirone, hydroxyzine), Parkinson’s medications (carbidopa-levodopa, amantadine), COPD and inhaler therapies, eye drops, vitamins, supplements, antibiotics, and various GI and pain medications. For each of these residents, the MARs showed blank spaces without documentation that the medications were administered, held, refused, or otherwise accounted for, contrary to facility policy and professional standards of medication administration and documentation. Across the sampled residents, the pattern of blank MAR entries demonstrated that staff did not consistently administer or document physician-ordered medications and treatments as required. The failures encompassed time-sensitive medications such as insulin and antibiotics, chronic disease management medications, anticoagulants, anticonvulsants, and psychotropic agents. The report does not describe any contemporaneous documentation explaining the omissions, nor does it show that the required notations and explanatory notes were made when doses were not given. These inactions and documentation gaps, combined with resident reports of missed medications and elevated blood sugars, form the basis of the cited deficiency for not meeting professional standards of quality in medication administration and documentation.
Failure to Perform and Document Neuro Checks After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide post-fall neurological assessments in accordance with its own Fall Evaluation and Prevention policy and acceptable standards of practice for three residents after unwitnessed falls. The policy, dated 8/2020, requires that following a fall, staff promptly evaluate the resident, obtain vital signs, perform a neurological evaluation, and, if the fall is unwitnessed or there is loss of consciousness, initiate neuro checks for at least 72 hours. The Interim DON and Previous Administrator stated they expected nurses to complete a head-to-toe assessment, obtain vital signs, start neuro checks for unwitnessed falls or head strikes, notify the physician, family/Resident Representative, and DON, and document post-fall monitoring once per shift for 72 hours. For one resident with diagnoses including hypertension, anxiety, restless leg syndrome, and spinal pain, an unwitnessed fall from bed occurred in the early morning hours. The incident report documented that the resident was found lying on their back on the floor with a skin tear to the left elbow and bruising on the left scapula, reported pain at a level seven out of ten, and received a skin assessment, vital signs, wound care, and PRN pain medication. The DON and physician were notified, but the family/emergency contact was not notified of the fall, and review of the medical record showed no documentation that neuro checks were completed following this unwitnessed fall. Another resident with moderate cognitive impairment and diagnoses including dementia, Parkinson’s disease, stroke, seizure, and repeated falls experienced an unwitnessed fall when they were found having slid from a wheelchair onto the floor in the hallway, resulting in a facial abrasion. Vital signs were obtained, hospice was contacted, and the resident was assisted to bed, with the DON and physician notified, but the family/responsible party was not notified. Record review showed no neuro checks were completed. A third resident with severe cognitive impairment and a history of prior falls, and diagnoses including seizure disorder, dementia, hypertension, sleep disorder, and osteoarthritis, had an unwitnessed fall while trying to get into bed. The incident report stated the resident did not hit their head, denied pain, and had no observed injuries, and noted that family and physician were aware with no new orders, but listed no people notified on the form. The medical record again showed no neuro checks completed for this unwitnessed fall.
Failure to Implement Post-Fall Interventions, Notify Families, and Follow Transfer Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management and evaluation policies after multiple unwitnessed falls and an injury during a staff-assisted transfer. For four residents who experienced unwitnessed falls, staff did not identify or implement new interventions to reduce the likelihood of additional falls, and the interdisciplinary team (IDT) did not document post-fall assessments or care plan revisions as required. The facility’s policies required completion of an incident report and post-fall assessment within 24 hours, root cause analysis, IDT review within 72 hours, and documentation of new interventions and care plan updates, but these steps were not carried out or documented for these residents. One cognitively intact resident with diagnoses including hypertension, anxiety, restless leg syndrome, and spinal pain had an unwitnessed fall from bed, resulting in a skin tear to the left elbow, bruising on the left scapula, and reported pain rated seven out of ten. The incident report showed the DON and physician were notified, but the resident’s family/responsible party was not notified, and there were no IDT notes or new interventions added to the care plan following the fall. Another resident with moderate cognitive impairment, dementia, Parkinson’s disease, stroke, seizures, and a history of repeated falls slid from a wheelchair to the floor in the hallway, sustaining a facial abrasion. The incident report documented notification of the DON and physician, but not the family/responsible party, and there were no IDT notes or additional interventions documented after this fall. A resident with severe cognitive impairment and multiple diagnoses including dementia, hypertension, stroke, diabetes, and anxiety had a fall with injury, with staff finding the resident on the floor with a swollen left wrist and complaints of hip pain, leading to transfer to the hospital. Although the incident report indicated the physician, DON, and a family member (by message) were notified, there was no post-fall risk evaluation, IDT documentation, or new interventions added to the care plan. Another resident with severe cognitive impairment, seizures, dementia, hypertension, sleep disorder, osteoarthritis, and a recent history of falls had an unwitnessed fall while trying to get into bed. The incident report noted no injuries and stated that family and physician were aware with no new orders, but listed no people notified, and there were no IDT notes or new interventions documented following this fall. The facility also failed to ensure that staff followed physician orders and the care plan for a resident requiring a full-body lift transfer with three staff. This resident, cognitively intact with diagnoses including heart failure, morbid obesity, anxiety, chronic pain syndrome, hypertension, muscle weakness, and right knee pain, had an order and care plan specifying transfer with a full-body lift and three people. The resident later reported that two agency CNAs transferred them with a Hoyer lift, turned them without informing them, and during lowering into the chair, the crossbar scraped their hand and wrist, causing a skin tear and bruising. There was no incident report, no skin assessment on the date of the incident, no documented notifications to the physician or responsible party, and no post-incident monitoring notes for 72 hours. Subsequent observation showed two CNAs performing the Hoyer transfer without a third staff member, and both CNAs stated they were unaware of the three-person transfer requirement in the care plan, indicating staff did not follow the ordered transfer protocol.
Failure to Administer and Document Seizure Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when ordered anticonvulsant and related medications were not administered or documented as given on multiple occasions. Facility policies required that physician orders be complete and accurately transcribed to the MAR, that medications be administered as prescribed, and that staff document administration directly after giving each dose. Policies also required that missed doses of vital medications be addressed and that seizure precautions consider missed anticonvulsant doses. Despite these policies, review of the resident’s paper MARs for February showed numerous blank administration boxes for scheduled doses of Depakote ER, levetiracetam, lacosamide, and lorazepam, with no explanatory documentation. The resident had moderate cognitive impairment and diagnoses including seizure disorder, repeated falls, dementia, Parkinson’s disease, and stroke. The care plan identified the resident as at risk for seizures with a goal to decrease seizure frequency, and approaches included administering medications as ordered. Physician orders included multiple scheduled anticonvulsants (Depakote ER in morning and bedtime doses, levetiracetam BID, lacosamide BID) and lorazepam 1 mg every 12 hours. MAR review showed Depakote ER 1,250 mg at bedtime was not documented as given on several dates, lacosamide and levetiracetam afternoon and morning doses were not documented as given on multiple dates, and lorazepam 1 mg scheduled every 12 hours was not documented as given for numerous morning and evening doses. A handwritten PRN lorazepam order and stat/PRN lorazepam orders from hospice on one date were partially documented with times but often without nurse initials, and there was no corresponding progress note describing seizure activity around the time those PRN orders were used. Staff interviews further described actions and inactions contributing to the deficiency. One LPN acknowledged documenting in a progress note that lorazepam had been given based on looking at a controlled substance count sheet, while admitting that some days nurses were not signing the paper MARs because it was “too much” work after CMTs were removed from passing certain medications. This LPN stated there were days when morning medications were not passed until after lunch and admitted not checking whether the resident’s other anti-seizure medications were being given as ordered because they could not keep up. A CMT reported working on a day when none of the resident’s medications were signed out on the day shift MAR and suggested the resident’s MARs might not have been in the binder, adding that some residents did not have MARs and the CMT did not know who they were or to whom this was reported. Another LPN reported witnessing the resident have multiple seizures in the dining room on one morning but did not write a progress note, stating the resident often had seizures. The hospice RN and the resident’s physician both reported increased seizure activity that month, and the physician specifically attributed the change to missed seizure medications at the facility and noted the resident had previously had an immediate seizure episode after missing just one dose of seizure medication.
Failure to Uphold Resident Dignity and Privacy Due to Unauthorized Video and Cell Phone Use
Penalty
Summary
Staff failed to treat a resident with dignity and respect when an LPN used a personal phone to record a video of a resident and posted it on a social media platform without obtaining written permission, as required by facility policy. The resident involved had severe cognitive impairment, multiple diagnoses including dementia and heart disease, and was on hospice care. The video, though not clearly identifying the resident, showed parts of the resident and the facility's unique carpet design, making the location recognizable. The LPN admitted to taking and posting the video, later removing it after realizing it was inappropriate. The Director of Nursing (DON) was informed of the incident but did not conduct a documented investigation or provide education or in-services to staff following the event. Additionally, staff were observed using personal cell phones in resident areas during mealtime, contrary to facility policy. During breakfast service, a CNA and the same LPN were seen scrolling and typing on their phones while in the dining room with residents. The Assistant Administrator and another staff member intervened, prompting the LPN to put away the phone, but the CNA continued to use their phone before assisting a resident. Staff interviews confirmed awareness of the policy prohibiting cell phone use in resident areas, but also revealed that no recent in-services had been provided regarding social media or personal phone usage. Facility policies clearly prohibit the use of personal electronic devices in resident areas and the sharing of resident information or images on social media without written consent. Despite these policies, staff actions demonstrated noncompliance, resulting in a failure to uphold residents' rights to dignity, respect, privacy, and confidentiality. The facility leadership acknowledged the expectation for staff to avoid personal phone use in resident areas and to refrain from recording or posting resident images, but these expectations were not consistently enforced.
Failure to Prevent Accidents and Ensure Safe Mechanical Lift Transfers
Penalty
Summary
Facility staff failed to ensure residents were free from accident hazards and did not provide adequate supervision during mechanical lift transfers, resulting in injuries to two residents. In one case, a cognitively intact resident with significant comorbidities, including morbid obesity, heart failure, diabetes, and polyneuropathy, was transferred using a Hoyer lift by two CNAs. During the transfer, the resident's right lower leg was struck, reportedly by the Hoyer lift remote control, despite the resident voicing pain and asking staff to be careful. The injury resulted in a rapidly growing hematoma, hospitalization, surgery for debridement, and the application of a wound vacuum. The resident consistently reported that staff did not listen to requests for caution during transfers, and the CNAs involved denied any incident or pain during the transfer. The facility's investigation into this incident was incomplete. The Director of Nursing (DON) interviewed the staff involved, who denied any improper actions, and did not document a conclusion or implement corrective measures. There was no evidence that the care plan was updated to prevent further accidents, and the required in-service training was not documented for the staff involved. The facility's policies required two staff for mechanical lift transfers, proper positioning, and monitoring to prevent injury, but these standards were not consistently followed or enforced. A second resident experienced two separate incidents involving improper Hoyer lift transfers. In one event, the resident's foot was bumped against the transfer pole, and in another, the resident was struck in the temple by the lift hook. Both incidents were documented, but the facility did not conduct thorough investigations or update the resident's care plan. The resident reported feeling unsafe during transfers, that staff did not listen to requests for caution, and described multiple near misses and rough handling. The DON was unaware of these incidents and did not recognize a pattern of improper mechanical lift use, despite multiple reports and resident complaints.
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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 Creve Coeur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creve Coeur Manor | 1.1 mi | ★★★★★ | 2 | 0 |
| River Crossing Rehab And Healthcare Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Brooking Park | 3.3 mi | ★★★★★ | 3 | 0 |
| Nhc Healthcare, Maryland Heights | 4.1 mi | ★★★★★ | 6 | 0 |
| Stonebridge Maryland Heights | 4.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.