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 Sunset Hills during CMS and state inspections, most recent first.
The facility failed to respect resident dignity, as evidenced by delayed meal service and lack of communication. A resident was denied a requested meal, another experienced a significant delay in being served, and staff ignored a resident's request for assistance. Additionally, staff entered rooms without knocking or introducing themselves, violating privacy protocols.
The facility failed to ensure that CNAs and CMTs received the required twelve hours of in-service education annually, based on their employment date. Eight out of ten sampled staff members did not meet this requirement, with some receiving as few as 3.35 hours of training. The facility's policy mandates training on compliance with laws and regulations, but records showed deficiencies in meeting these training requirements.
The facility failed to maintain accurate records for controlled drugs, with discrepancies in narcotic count sheets across multiple carts. Instances of pre-signing, missing signatures, and lack of dual staff presence during counts were observed, indicating a systemic issue in controlled substance management.
A LTC facility failed to prevent significant medication errors, affecting three residents. One resident with obstructive uropathy missed doses of bethanechol chloride due to unavailability, and the physician was not notified. Another resident with anxiety missed several doses of clonazepam, with no documentation of physician notification. A third resident with Parkinson's Disease received expired Rytary for over a week. Staff interviews revealed lapses in following medication administration protocols.
The facility failed to update care plans for residents with significant needs, including a resident with a history of self-harm, another with sexually inappropriate behaviors, and a third receiving hospice care. These deficiencies in documentation and monitoring were identified during a survey, highlighting the need for accurate and comprehensive care plans to address residents' medical and psychosocial needs.
A facility failed to manage a resident's knee wound according to professional standards. The staff did not document an assessment or notify the physician and family about the wound, nor was a physician's order obtained for a dressing. The resident, with a history of kidney failure, aphasia, dementia, anxiety, and depression, was found with a bandage on the knee, but staff were unaware of the wound's need for a dressing. The facility's policy requires immediate reporting and notification for skin concerns, which was not followed.
The facility failed to maintain a medication error rate below 5%, resulting in a 13.33% error rate. Errors included improper measurement of powdered medication, allowing a resident to self-administer nasal spray beyond the prescribed dose, crushing a medication that should not be crushed, and leaving medications unattended. These incidents involved two residents with multiple health conditions. Staff interviews revealed non-compliance with medication administration policies.
A resident with severe cognitive impairment and weight loss was not provided with therapeutic diets as recommended by the physician and RD. The resident did not receive fortified chocolate milk or additional food items listed on the meal ticket during observed meals. The resident's care plan was not updated with preferences, and the resident did not receive adequate assistance or encouragement to eat. Staff interviews revealed an expectation to follow dietician recommendations, but dietary staff failed to consistently provide the prescribed items.
Staff at the facility failed to follow hand hygiene protocols during incontinence care for two residents, neglecting to perform hand hygiene between glove changes. One resident, with a history of kidney failure and dementia, and another with severe cognitive impairment and on Enhanced Barrier Precautions, were both subject to care where staff did not consistently use hand sanitizer or wash hands after glove removal. Interviews with staff confirmed the expectation for hand hygiene, indicating a lapse in adherence to infection control policies.
A resident with dementia and Parkinson's Disease was physically abused by an agency CNA, who punched the resident in the neck after being hit during care. The CNA, unfamiliar with the facility's abuse policy, did not report the incident. The resident's care plan highlighted a history of resisting care, requiring calm redirection, which was not followed.
A resident with a history of COPD and heart failure was not properly monitored after exhibiting symptoms of vomiting and distress. Despite being given Zofran, there was no documentation, and the resident's condition deteriorated overnight, leading to emergency hospitalization for respiratory failure and septic shock. Interviews revealed a lack of proper documentation and communication among staff.
Deficiencies in Resident Dignity and Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving meal service and communication. Resident #91, who has moderate cognitive impairment and other health issues, requested a bacon, lettuce, and tomato (BLT) sandwich for lunch but was told by a dietary aide to wait until dinner. Instead, the resident was served pasta con broccoli, which they ate only 25% of, while their tablemates received the requested BLT sandwiches. The Food Service Manager and the Director of Nursing (DON) later confirmed that residents should not have to wait for requested food items. Resident #109, with severe cognitive impairment and other health conditions, experienced a delay in meal service. While seated at a table with two other residents, Resident #109 was served significantly later than their tablemates, with a delay of over 30 minutes. The dietary staff initially placed the resident's meal out of reach and did not provide the ordered fruit. The DON and Administrator acknowledged that such delays are not dignified and that residents should be served at approximately the same time. Additionally, Resident #44, who has severe cognitive impairment and hearing difficulties, was ignored by staff when asking to be taken back to their room after dinner. Staff members did not respond to the resident's repeated inquiries. Furthermore, staff members entered the rooms of Residents #67, #102, and #110 without knocking or introducing themselves, which violates the facility's policy on respecting residents' privacy and dignity. Interviews with staff confirmed that knocking and introducing oneself is expected protocol, regardless of the resident's cognitive status.
Deficiency in Annual In-Service Training for CNAs and CMTs
Penalty
Summary
The facility failed to ensure that each nurse aide received no less than twelve hours of in-service education per year, calculated based on their employment date rather than the calendar year. This deficiency was identified for eight out of ten sampled Certified Nursing Assistants (CNAs) and Certified Medication Technicians (CMTs). The facility's Compliance Education and Training Policy, dated 7/1/2019, mandates that all employees receive training on compliance with laws, regulations, facility policies, and procedures. However, the review of individual employee files revealed that several CNAs and a CMT did not meet the required twelve hours of in-service training within their respective tracking periods. The facility's assessment tool outlined various training requirements, including effective communication, resident rights, abuse prevention, infection control, and cultural competency, among others. Despite these outlined requirements, the in-service tracking records showed deficiencies in meeting the twelve-hour training requirement for several staff members. For instance, CNA A received only 5.15 hours, CNA N received 3.35 hours, and CMT P received 10.85 hours of training during their respective tracking periods. During an interview, the Administrator acknowledged the expectation for staff to complete the required annual education as per federal and state guidelines.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to establish a system of records for all controlled drugs with sufficient detail to enable accurate reconciliation. This deficiency was identified through observation, interview, and record review, affecting all ten narcotic count books reviewed. The facility's policy mandates that only authorized licensed nurses or pharmacy personnel have access to Schedule II controlled drugs, and controlled substances must be counted upon delivery and at the end of each shift by both the outgoing and incoming staff. However, the review revealed multiple instances where these procedures were not followed, including pre-signing of narcotic count sheets, lack of dual staff presence during counts, and missing signatures and documentation on narcotic count sheets. Specifically, the review of various controlled drug count sheets from different carts showed numerous discrepancies. For instance, the 1a Certified Medication Technician (CMT) cart had pre-signed entries and counts performed without another staff member present. Across multiple carts, there were missing outgoing and incoming staff signatures, and several instances where the number of packages was not documented. These lapses occurred repeatedly over the review period, indicating a systemic issue in maintaining accurate records for controlled substances. During an interview, the Director of Nursing (DON) and Administrator acknowledged that the narcotic count should be conducted at the beginning and end of each shift with two staff members present, and the count sheets should be signed at the time of completion. They confirmed that they would not expect blank spots on the narcotic sheets, highlighting a failure to adhere to the facility's policy and procedures for controlled substance management.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of missed doses and administration of expired medications. Resident #29, who had severe cognitive impairment and a diagnosis of obstructive uropathy, did not receive several doses of bethanechol chloride, a medication necessary for urinary retention. The medication was documented as unavailable on multiple occasions, and the staff failed to utilize stock medications or notify the resident's physician about the missed doses. Resident #110, who had a diagnosis of anxiety among other conditions, missed several doses of clonazepam, a medication used to manage anxiety. The medication was not available in the Pyxis system, and there was no documentation of the physician or family being notified about the missed doses. Interviews revealed that the staff was unaware of the missed doses, and the facility's protocol for handling unavailable medications was not followed. Resident #227, diagnosed with Parkinson's Disease, was administered an expired medication, Rytary, for over a week. The medication was brought in by the family, and the staff failed to check the expiration date before administration. The DON acknowledged that expired medications should not be given due to potential ineffectiveness. The Medical Director confirmed that expired medications might not provide the intended therapeutic effect, although no adverse effects were reported. The facility's failure to adhere to medication administration policies resulted in significant medication errors for these residents.
Care Plan Deficiencies in Resident Monitoring and Documentation
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurate to reflect the needs of the residents, affecting three out of four sampled residents. Resident #96, who had severe cognitive impairment and a history of self-harm, was not adequately monitored or documented in the care plan regarding their suicide attempt. Despite the resident's history of self-harm and a recent incident involving scissors, the care plan did not mention the suicide attempt or the need for increased supervision and monitoring. Interviews with staff revealed that the resident had a private caregiver, but the care plan did not reflect this arrangement, nor did it include the necessary precautions to prevent further self-harm. Resident #109, who also had severe cognitive impairment, exhibited sexually inappropriate behaviors that were not documented in the care plan. The resident made inappropriate comments and attempted to touch staff during care, behaviors that were known to the staff and had been occurring since admission. Despite these ongoing issues, the care plan did not address the resident's sexual behaviors or provide guidance for staff on how to manage these behaviors effectively. Interviews with staff indicated that these behaviors were reported and documented in the medical record, but the care plan was not updated to reflect these concerns. Resident #29 was admitted to hospice care, but the care plan did not include documentation of the hospice services being provided. The resident had a diagnosis of terminal senile degeneration of the brain and was receiving hospice visits multiple times a week. However, the care plan failed to reflect the hospice care and the specific services being provided, such as assistance with transfers, personal care, and monitoring of the resident's condition. The Director of Nursing acknowledged that the care plan should have been updated to include hospice services, but it was not clear why this was overlooked.
Failure to Manage Resident's Knee Wound
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards, specifically regarding the management of a knee wound. The staff did not complete a documented assessment or notify the physician and family about the resident's knee wound. Additionally, there was no physician's order obtained for a dressing on the resident's right knee. The resident, who had a history of kidney failure, aphasia, dementia, anxiety, and depression, was observed with a small bandage on the right knee, but the nursing staff were unaware of the wound requiring a dressing. The facility's Prevention and Treatment of Skin Breakdown policy requires immediate reporting of skin concerns to a designated nurse and notification of the physician and resident representative when a wound is found. However, the January 2025 progress notes and physician's orders sheet showed no documentation or treatment orders for the resident's right knee prior to January 27, 2025. Interviews with staff revealed a lack of awareness and communication regarding the wound, and the resident's physician expressed an expectation for prompt notification of any skin integrity issues. The Director of Nursing and the Administrator also emphasized the importance of following the facility's policies on skin and wounds.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 13.33% error rate during the survey. This was observed through four errors out of 30 medication administration opportunities. The errors involved improper measurement of a powdered medication, allowing a resident to self-administer nasal spray beyond the prescribed dose, crushing a medication that should not have been crushed, and leaving crushed medications unattended on the medication cart. These incidents involved two residents, one with renal disease, diabetes, congestive heart failure, atrial fibrillation, dementia, and depression, and another with osteoporosis, atherosclerotic heart disease, high cholesterol, kidney failure, atrial fibrillation, and dementia. During the medication administration observations, a Certified Medication Technician (CMT) improperly measured Psyllium husk powder and allowed a resident to self-administer Flonase nasal spray, resulting in an overdose. Another incident involved the CMT crushing Ezetimibe, a medication that should not be crushed, and leaving it unattended on the medication cart. Interviews with staff revealed a lack of adherence to the facility's medication administration policies, including the proper procedure for measuring and administering medications, and the requirement for staff to ensure medications are not left unattended. The Director of Nursing and the Administrator both expressed expectations for staff to follow the facility's policies and procedures regarding medication administration.
Failure to Provide Therapeutic Diets and Assistance
Penalty
Summary
The facility failed to ensure that a resident with weight loss was provided with therapeutic diets as recommended by the physician and the Registered Dietitian (RD). The resident, who had severe cognitive impairment and required supervision for eating, was not given fortified chocolate milk during two observed meals. Additionally, the extra items listed on the meal ticket, such as fruit and yogurt, were not provided. The resident's care plan was not updated to reflect the resident's preferences for these items, despite the RD's recommendations. Observations in the dining room revealed that the resident was not consistently receiving the fortified chocolate milk or the additional food items as prescribed. On multiple occasions, the resident's meal was placed out of reach, and the resident did not receive adequate assistance or encouragement to eat. The resident's spouse expressed concerns about the lack of assistance and the failure to provide the extra items when the spouse was not present. Interviews with staff, including the RD, DON, and Administrator, indicated that there was an expectation for dietary staff to follow the dietician's recommendations and the meal ticket instructions. However, the dietary staff did not consistently provide the fortified chocolate milk or notify nursing staff when it was not given. The resident's weight continued to decline, and the RD noted that the resident was on a watch list for weight loss.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding hand hygiene during incontinence care for two residents. The facility's policy mandates hand hygiene, including the use of alcohol-based hand rub (ABHR) or soap and water, particularly after glove removal. However, during observations, staff members did not consistently perform hand hygiene between glove changes while providing care to the residents. For Resident #110, who has a history of kidney failure, aphasia, dementia, anxiety, and depression, staff members CNA B and CNA C were observed providing incontinence care without performing hand hygiene between glove changes. Despite using hand sanitizer once, CNA C failed to use it consistently after removing gloves, even after cleaning stool from the resident. This lack of adherence to hand hygiene protocols was observed multiple times during the care process. Similarly, for Resident #44, who has severe cognitive impairment and is on Enhanced Barrier Precautions due to wounds, CNA G and CNA H also neglected to perform hand hygiene between glove changes. They were observed changing gloves multiple times without using hand sanitizer or washing their hands, despite handling soiled briefs and dressings. Interviews with staff, including a CNA, an LPN, and the Director of Nurses, confirmed the expectation for hand hygiene between glove changes, highlighting the facility's failure to follow its own infection control policies.
Resident Abuse by Agency CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by an agency Certified Nurse Aide (CNA). On the morning of March 17, 2024, a video recording showed the CNA standing at the resident's bedside, with one hand behind the resident's neck and the other pulling on the resident's leg to assist them into a sitting position. The resident, who has a history of resisting care due to dementia, hit the CNA. In response, the CNA punched the resident in the neck and verbally questioned the resident's actions. The incident was not reported by the CNA to the Charge Nurse, as the CNA did not consider it at the time and was unfamiliar with the facility's abuse and neglect policy. The resident involved in the incident has severe cognitive impairment, diagnosed with dementia and Parkinson's Disease, and is dependent on assistance for activities of daily living. The resident's care plan noted a history of resisting care and becoming combative, with strategies outlined for staff to manage such behaviors. Despite these documented needs, the CNA's actions were contrary to the care plan's approaches, which emphasized calm and consistent redirection during episodes of inappropriate behavior. The facility's investigation revealed that the CNA had read and accepted the facility's abuse and neglect policy prior to the incident. However, the CNA admitted to hitting the resident back after being struck and did not report the incident. The facility's staff, including the Administrator and Medical Director, expected adherence to the abuse and neglect policy, but the CNA's actions and failure to report the incident indicated a breach of this policy.
Failure to Monitor Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that a resident who experienced a change in condition was properly monitored and assessed by a licensed nurse throughout the night. The resident, who had a history of chronic obstructive pulmonary disease (COPD), chronic heart failure, and other significant health issues, was brought back to the facility by a family member and exhibited symptoms of vomiting and distress. Despite the administration of Zofran by an LPN, there was no documentation of the medication being given, and the resident was not adequately monitored throughout the night as per the facility's policy on acute changes in condition. The night shift LPN did not check on the resident during the night, relying instead on CNAs to report any changes. The resident's condition deteriorated overnight, and by the next morning, the resident was found to have labored breathing, wheezing, and a significantly low oxygen saturation level. Emergency services were called, and the resident was transported to the hospital, where they were intubated and admitted to the ICU for respiratory failure, atrial fibrillation, and septic shock. Interviews with the involved staff revealed a lack of proper documentation and communication regarding the resident's condition and the administration of medication. The facility's Director of Nursing acknowledged that the staff did not follow the facility's change in condition policy, and the resident's physician emphasized the importance of monitoring a resident with a change in condition. The failure to monitor and document the resident's condition and treatment led to a significant decline in the resident's health, necessitating emergency medical intervention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 941 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Fountain Care At Sunset Hills | 0.4 mi | ★★★★★ | 3 | 0 |
| Fieser Nursing Center | 1.8 mi | ★★★★★ | 22 | 0 |
| Delmar Gardens South | 3 mi | ★★★★★ | 0 | 0 |
| Maple Grove Wellness & Rehabilitation | 3.1 mi | ★★★★★ | 24 | 0 |
| Delmar Gardens Of Meramec Valley | 3.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Friendship Village Sunset Hills.
100% money-back within 48 hours.
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.