Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Friendship Village Chesterfield during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, bilateral extremity impairment, and multiple comorbidities required substantial/maximal assistance for transfers per MDS and care plan. During a morning transfer from bed to wheelchair, a CNA positioned the wheelchair beside the bed but did not lock the brakes or apply a gait belt. While the resident sat at the edge of the bed, the CNA lifted and pivoted the resident by pulling on the resident’s pants and supporting under one arm, attempting to seat the resident in the wheelchair. The resident landed on the edge of the unlocked wheelchair, which rolled backward, causing both the resident and the CNA to fall to the floor.
A resident with severe cognitive impairment and mobility issues was left alone in the bathroom and improperly assisted during transfers, leading to a deficiency in dignity and care. The resident, who required assistance with daily activities, was observed performing personal care without help while a CNA displayed inappropriate behavior. The facility's DON and Administrator reviewed video footage showing the CNAs' actions, which were deemed inappropriate and not in line with care expectations.
The facility failed to prevent accident hazards, resulting in injuries to residents due to improper use of mechanical lifts. One resident suffered a fracture from an inappropriate sit-to-stand lift transfer, and another was improperly connected to a Hoyer lift, causing the wheelchair to lift with the resident seated. Staff did not adhere to protocols requiring two staff members for transfers, leading to unsafe conditions.
The facility failed to properly label and store medications, with expired drugs found in medication rooms and carts. Additionally, medication carts were left unlocked and unattended, posing a risk to residents. Staff interviews revealed a lack of formal auditing processes for expired medications and inconsistent enforcement of cart security protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper PPE use for residents with wounds and COVID-19. Staff did not consistently wear gowns or N-95 masks, and EBP signage was missing. Confusion among staff about EBP requirements and improper mask use during a COVID-19 outbreak were observed.
The facility did not ensure CNAs completed the required 12 hours of annual training. Four CNAs, including a CMT, did not meet the training requirement, with hours ranging from 0 to 11.7. The facility lacked a policy for the training, and staff were expected to complete it independently by their anniversary date.
The facility failed to conduct and document required neurological assessments following unwitnessed falls for two residents, one with Parkinson's and dementia and another with a history of stroke and dementia. Despite the facility's policy, no neuro checks were recorded, even though one resident reported hitting their head. Staff interviews confirmed the absence of documentation, highlighting a lapse in adhering to established procedures.
Two residents in a facility were not provided with necessary assistance for activities of daily living (ADLs), including grooming and personal hygiene. One resident, with multiple sclerosis and dementia, was observed wearing the same stained gown for days and had untrimmed nails, despite expressing a desire for care. Another resident, with upper extremity impairments, reported receiving showers only once a week, contrary to their preference for more frequent showers. Staff interviews confirmed the lack of adherence to expected care routines.
A facility failed to provide necessary dialysis communication forms for a resident receiving hemodialysis. Despite the facility's policy requiring documentation and communication with the dialysis center, no forms were sent with the resident, as confirmed by staff interviews. The resident's care plan did not address hemodialysis treatments, and the DON confirmed the absence of completed communication forms in the medical record.
The facility failed to maintain a medication administration error rate below 5%, resulting in a 12% error rate. Two residents did not receive their prescribed medications due to unavailability on the medication cart and in the emergency kit. The Director of Nursing confirmed that medications should be administered as per physician orders, and if unavailable, staff should document them as not given and administer them at the next appropriate time.
An LPN in a facility was found to have misappropriated Norco, a controlled substance, by falsifying records and signing out excessive amounts for residents who did not request or require it. The issue was discovered when another LPN noticed discrepancies in medication records, leading to an investigation where the LPN confessed to taking the medications for personal use due to addiction.
The facility failed to document the administration and effectiveness of controlled substances for four residents, did not update medication orders on the IPNR, and omitted necessary signatures and dates for received medications. These lapses in documentation and adherence to policies potentially affected all residents with pain medication orders.
The facility failed to maintain a comprehensive system for documenting and reconciling controlled substances, leading to incomplete shift change count sheets and inadequate documentation of medication destruction. This affected residents prescribed controlled substances for pain management, with no clear records of how discontinued medications were handled.
The facility failed to prevent further misappropriation of controlled substances by not suspending an LPN during an investigation. The LPN continued working, leading to further misappropriation involving three residents. The facility also did not conduct a thorough investigation, failing to interview additional staff and residents as required by policy. This oversight had the potential to affect all residents with controlled substance orders.
Failure to Use Gait Belt and Lock Wheelchair During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance and accident prevention during a transfer when staff did not follow established safe transfer protocols. The facility’s Transfer Techniques policy required staff to lock wheelchair brakes, raise foot pedals, and use a gait belt during transfers from bed to wheelchair. The policy also directed staff to ensure residents wore proper fitting, non-skid footwear, to lock bed and wheelchair wheels, and to use a gait belt while assisting the resident to stand, pivot, and sit in the wheelchair with proper alignment. The resident involved had a quarterly MDS showing severe cognitive impairment, upper and lower extremity impairment on both sides, and a need for substantial/maximal assistance with transfers, meaning a helper provided more than half the effort and lifted or held the trunk or limbs. The resident’s diagnoses included heart failure, hypertension, diabetes, Alzheimer’s disease, and reduced mobility. The care plan identified a self-care and mobility deficit, with the resident requiring supervision and assistance to complete care, and specified transfer assistance ranging from contact guard assist to extensive assist by one staff member for stand-and-pivot transfers. On the morning of the incident, video reviewed by the facility and the resident representative showed a CNA entering the resident’s room, dressing the resident, and later returning with a mechanical lift. The CNA sat the resident on the edge of the bed, changed the resident’s shirt, and placed a jacket on the resident. The CNA then pulled the resident’s wheelchair to the left side of the bed without locking the wheelchair brakes and did not apply a gait belt. While standing at the resident’s side, the CNA used one hand to pull up the resident’s pants and the other hand under the resident’s arm, counted to three, and attempted to lift and pivot the resident into the wheelchair. The resident landed only on the edge of the unlocked wheelchair, which rolled backward, causing both the resident and the CNA to fall to the floor, with the resident landing on the right side. The CNA later acknowledged that a gait belt and locked wheelchair should be used when transferring a resident and that these were not used at the time of the fall.
Resident Dignity and Care Deficiency
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by multiple incidents involving a resident with severe cognitive impairment and mobility issues. The resident, who required staff assistance with mobility and personal care, was left alone in the bathroom while seated on the toilet and again while hovering over the toilet. During these times, a Certified Nurse Aide (CNA) made comments about their dislike of the job and the level of care the resident required. Additionally, during a transfer from the wheelchair to the bed, the resident was not properly assisted and was left with legs hanging off the bed. The resident's medical history included severe cognitive impairment, high blood pressure, orthostatic hypotension, acid reflux, dementia, Parkinson's disease, and depression. The resident required supervision or assistance with various activities of daily living, including toileting hygiene, sit-to-stand transfers, and chair/bed transfers. Despite these needs, the resident was observed performing personal care without staff assistance while a CNA stood in the doorway, clapping hands, snapping fingers, and swaying side to side. The facility's Director of Nursing (DON) and Administrator reviewed video footage provided by the resident's family, which showed inappropriate behavior by the CNAs. The DON noted that the aides were moving too fast and that it was not appropriate for the resident to be left alone on the toilet or for the resident to be transferred in a manner that left their lower half hanging off the bed. The Administrator acknowledged that the behavior of the aides was not appropriate and not in line with the facility's expectations for resident care.
Improper Use of Mechanical Lifts Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, as evidenced by improper use of mechanical lifts, leading to injuries. One resident sustained a minimally displaced sub-acute chip fracture along the anterior surface of the talus, reportedly due to improper handling during a Hoyer lift transfer. The investigation revealed that the resident had been transferred using a sit-to-stand lift, which was inappropriate given the resident's inability to stand safely. Additionally, a CNA admitted to operating the Hoyer lift alone, contrary to the facility's policy requiring two staff members for such transfers. Another incident involved a resident being improperly connected to a Hoyer lift, resulting in the wheelchair being lifted approximately one foot into the air with the resident seated. This incident highlighted a failure to ensure the resident's safety during transfers, as the Hoyer pad was not correctly attached, causing the chair to rise with the resident. The facility's policy mandates that two staff members assist with mechanical lift transfers to prevent such hazards. The facility's documentation and staff interviews revealed a lack of adherence to established transfer protocols, contributing to the unsafe conditions. Staff were not consistently following the care plans and mechanical lift policies, which specify the use of appropriate equipment and the need for two staff members during transfers. The facility's failure to ensure proper training and supervision of staff in using mechanical lifts resulted in preventable injuries to residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an observation of the first-floor medication room, several expired medications and biologicals were found, including Milk of Magnesia, Albuterol Sulfate inhalation aerosol solution packets, Covidien Xeroform Occlusive gauze strips, KerraFoam gentle border foam dressings, and Divalproex tablets. Additionally, a Glucagen Hypokit and a punch card for Senokot were found expired on medication carts. Interviews with staff revealed a lack of a formal process for auditing medication carts and rooms for expired medications, with responsibilities vaguely assigned to night shift staff and random audits requested by facility administration. The report also highlighted issues with medication cart security. On multiple occasions, a medication cart on the Grand Unit was observed unlocked and unattended by staff, posing a potential risk to residents, especially those with dementia. A Certified Medication Technician (CMT) was seen leaving the cart unattended while assisting residents, despite the expectation that carts should be locked when not in use. Interviews with staff confirmed that medication carts should be locked when unattended to ensure resident safety. The Director of Nursing (DON) and the facility Administrator both acknowledged the responsibility of staff to audit medication rooms and carts for expired medications and to ensure that medication carts are locked when not in use. However, the report indicates a lack of consistent procedures and enforcement of these expectations, contributing to the deficiencies observed during the survey.
Infection Control Deficiencies in EBP and COVID-19 Precautions
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS. This deficiency was observed in the care of residents with central lines, dialysis access sites, and wounds requiring treatment. Specifically, for two residents, the facility did not display EBP signage outside their rooms, and staff did not wear the required gowns during high-contact care activities. Interviews with staff revealed a lack of understanding and inconsistent application of EBP, with some staff believing that EBP only required glove use, while others were unsure of the requirements. Additionally, the facility did not ensure that staff wore N-95 respirator masks in rooms of residents positive for COVID-19, who were on airborne and droplet precautions. Observations showed that staff entered and exited these rooms without the appropriate PPE, and surgical masks were not worn properly on the first floor, where a COVID-19 outbreak was identified. Interviews with staff and the Director of Nursing confirmed that there was an expectation for surgical masks to be worn at all times on the first floor, but this was not consistently followed. The facility's policies on EBP and COVID-19 precautions were not effectively implemented, leading to lapses in infection control. The Infection Preventionist and other staff members expressed confusion over the application of EBP, particularly regarding wounds, and there was a lack of clear communication and enforcement of PPE requirements. The Administrator and Director of Nursing acknowledged the deficiencies and the need for proper signage and PPE use, but these measures were not consistently applied during the survey period.
Deficiency in CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of ongoing education annually. This deficiency was identified for four out of five sampled CNAs, including CNA Q, CNA N, Certified Medicine Technician (CMT) R, and CNA P. Specifically, CNA Q, hired on 5/18/23, completed 0 hours of training; CNA N, hired on 3/23/23, completed 3 hours; CMT R, hired on 3/16/09, completed 10.6 hours; and CNA P, hired on 10/2/14, completed 11.7 hours. The facility did not provide a policy related to the 12-hour training requirement. Interviews with the Director of Nursing (DON) and the Administrator revealed that CNAs were expected to complete their training by their anniversary date independently, without reminders.
Failure to Conduct and Document Neuro Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to adhere to its own policies regarding neurological assessments following unwitnessed falls, resulting in a deficiency. Two residents, one with Parkinson's disease and dementia and another with a history of stroke and dementia, experienced unwitnessed falls. Despite the facility's policy requiring immediate neurological checks in such cases, these assessments were not documented for either resident. This oversight occurred even though one resident reported hitting their head during a fall. Resident #41, who has multiple diagnoses including Parkinson's disease and dementia, experienced two unwitnessed falls. On both occasions, the resident's medical records lacked documentation of the required neurological checks. The resident was on a blood thinner, which increases the risk of complications from head injuries, yet no neuro checks were performed or recorded. Similarly, Resident #27, with a history of stroke and dementia, also experienced an unwitnessed fall, and no neuro checks were documented in their medical records. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed the absence of documentation for the required neuro checks. The staff acknowledged the importance of these assessments, particularly for residents on blood thinners or those unable to communicate effectively. Despite this understanding, the facility failed to ensure that neuro checks were completed and documented, as required by their policies, following the unwitnessed falls of these residents.
Deficiencies in Resident Hygiene and ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. Resident #24, who is cognitively intact but has multiple sclerosis, dementia, and depression, was observed over several days wearing the same stained hospital gown and having long, jagged fingernails with a light brown substance underneath. Despite the resident expressing a desire to have their nails trimmed and to be assisted out of bed, staff did not provide the necessary care. Interviews with staff revealed that the resident did not refuse care, yet the expected daily hygiene and grooming tasks were not completed. Resident #11, who is cognitively intact but has impairments in both upper extremities, was also not receiving adequate assistance with ADLs. The resident, who requires some assistance with showering and bathing, reported only receiving showers once a week, despite expressing a preference for more frequent showers. Observations confirmed the resident's hair appeared oily, indicating a lack of regular hygiene care. Staff interviews corroborated the resident's need for assistance with showering, including covering a Quinton catheter, but the facility failed to meet these needs consistently. Interviews with the Director of Nurses and the Administrator highlighted expectations for staff to provide daily nail care, change hospital gowns, and offer assistance with getting residents out of bed. However, these expectations were not met, as evidenced by the observations and resident interviews. The facility's failure to adhere to its own policies and procedures for morning care and hygiene resulted in deficiencies in the care provided to Residents #24 and #11.
Failure to Provide Dialysis Communication Forms
Penalty
Summary
The facility failed to provide necessary pre-assessment and post-assessment communication forms to the dialysis center for a resident receiving hemodialysis. The facility's Hemodialysis Access Policy requires documentation of the hemodialysis access point, condition of the dressing, prior dialysis dates, reports from the dialysis clinic RN, post-dialysis observations, and physician notifications of unusual observations. However, the resident's care plan did not address hemodialysis treatments, and no communication forms were sent with the resident to the dialysis center, as confirmed by interviews with the resident and facility staff. The resident, who was cognitively intact and diagnosed with heart failure, end-stage renal disease, and diabetes, reported attending dialysis sessions three times a week without any accompanying paperwork. Interviews with an LPN and RN revealed that no forms were sent with dialysis residents, except for the physician order sheet on the first day of treatment. The DON confirmed the absence of completed dialysis communication forms in the resident's medical record, indicating a failure to adhere to the facility's policy for dialysis communication.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 12% error rate. This deficiency was identified through observation, interview, and record review, affecting two residents. The facility's policy requires that all personnel administering medications ensure the correct medication, dose, person, administration time, and route. However, during the medication administration process, Certified Medication Technician (CMT) I was unable to administer the prescribed medications to two residents due to their unavailability on the medication cart and in the emergency kit. For Resident #34, the prescribed Refresh Tears eye drops were not available, and CMT I did not administer them on the scheduled day. Similarly, for Resident #9, the prescribed PreserVision eye drops and Thera-M multivitamin were missing, and CMT I did not administer these medications. The Director of Nursing confirmed that medications should be administered as per physician orders, and if unavailable, staff should document them as not given and administer them at the next appropriate time. The failure to administer these medications as ordered contributed to the facility's medication error rate exceeding the acceptable threshold.
Misappropriation of Controlled Substances by LPN
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of controlled substances by a staff member, specifically involving the unauthorized removal of Norco, a pain medication, for four residents. The issue was brought to light when an LPN noticed discrepancies in the medication sign-out records, particularly when another LPN, who was later identified as the perpetrator, was on duty. The LPN in question was observed signing out excessive amounts of Norco for residents, even when they did not request or require it, and often at times when they were unlikely to take it, such as late at night. Upon investigation, it was found that the LPN had been falsifying narcotic records, documenting the administration of Norco to residents who later confirmed they had not received the medication. Interviews with alert residents revealed that they had not been given the medication at the times recorded by the LPN. The facility's Director of Nursing (DON) and Administrator conducted interviews and reviewed video footage, which did not provide evidence of the medication being administered as documented. The LPN eventually confessed to taking the medications for personal use due to an addiction problem. The facility's failure to monitor and verify the accurate administration of controlled substances led to this deficiency. The lack of oversight allowed the LPN to continue the misappropriation over an extended period, affecting multiple residents. The issue was compounded by the fact that the facility's management did not act on initial concerns raised by another LPN until a formal complaint was made, highlighting a gap in the facility's internal controls and reporting mechanisms.
Deficiencies in Controlled Substance Documentation and Pain Management
Penalty
Summary
The facility failed to properly document the administration of controlled substances and the effectiveness of pain medication for four sampled residents. This included not recording the administration of narcotics on the Individual Patient Narcotic Record (IPNR) and the electronic Treatment Administration Record (eTAR). Additionally, the facility did not document the effectiveness of the pain medication after it was administered. This lack of documentation was observed for all four residents who were part of the sample. The facility also failed to update the IPNR when there were changes in medication orders. This oversight was noted in the records of the sampled residents, where the orders for pain medications were not updated to reflect changes in dosage or frequency. Furthermore, the facility did not document the signature of the nurse receiving the controlled medication and the date it was received, which is a critical step in ensuring accountability and compliance with controlled substance regulations. The deficiencies in documentation and record-keeping had the potential to affect all residents with pain medication orders and controlled substance orders. The facility's policies on controlled substances and pain management were not adhered to, as evidenced by the discrepancies in the narcotic records and the lack of documentation on the effectiveness of pain management interventions. These failures highlight significant lapses in the facility's medication management processes, which are essential for ensuring the safety and well-being of residents.
Inadequate Documentation and Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to establish a comprehensive system for the documentation and reconciliation of controlled substances, which are medications regulated by the DEA due to their potential for dependency and abuse. This deficiency was identified through interviews and record reviews, revealing that the facility did not maintain detailed records of the disposition of controlled substances, making accurate reconciliation impossible. Specifically, the facility's controlled substance shift change count sheets were inadequately completed, with only one staff member's initials present in numerous instances across several months. This lack of proper documentation and oversight was noted in the records of three out of three controlled substance shift change count sheets reviewed. Additionally, the facility did not have a system in place to document the destruction of controlled substances adequately. For four sampled residents, there was no documentation on what was done with the remaining controlled medications after they were discontinued. The records showed that medications were marked as discontinued, but there was no accompanying documentation to indicate how these medications were destroyed or disposed of. Interviews with the DON and ADON revealed that the facility relied on a drug buster system for medication destruction but did not document this process, leaving a gap in the accountability and tracking of controlled substances. The deficiency affected residents who were prescribed controlled substances for pain management, including those with conditions such as osteomyelitis, paraplegia, and fractures. The facility's failure to document the destruction of controlled substances and to ensure accurate shift-to-shift counts of these medications posed a risk to all residents with controlled substance orders. The lack of a formal education program for nursing staff on the importance of completing and documenting these counts further contributed to the deficiency, as acknowledged by the ADON and Administrator during interviews.
Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent further misappropriation and diversion of controlled substances by not adhering to its policy for suspension during an investigation. An LPN reported alleged violations of misappropriation by another LPN, who was allowed to continue working while the facility investigated the allegations. This resulted in the continued misappropriation of medications for three residents. The facility's policy required immediate suspension of the accused individual to protect residents, which was not followed. Additionally, the facility did not conduct a thorough investigation as required by its policy. The investigation did not include interviews with additional staff and residents who might have been involved or affected by the misappropriation. The facility's policy mandates a comprehensive investigation process, including interviews with all involved parties and a review of relevant documentation, which was not fully executed in this case. The failure to follow the facility's policy for suspension and thorough investigation had the potential to affect all residents with controlled substance orders. The facility's census was 82, indicating a significant number of residents could have been impacted by the misappropriation of medications. The lack of immediate action and comprehensive investigation compromised the safety and well-being of the residents.
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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 Chesterfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westchester House, The | 0.5 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens Of Chesterfield | 1 mi | ★★★★★ | 0 | 0 |
| Surrey Place St Lukes Hospital Skilled Nursing | 1 mi | ★★★★★ | 0 | 0 |
| Garden View Care Center Of Chesterfield | 1.2 mi | ★★★★★ | 1 | 0 |
| Mason Pointe Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
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