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 Lutheran Convalescent Home during CMS and state inspections, most recent first.
A facility was found to have a medication error rate of 14.81%, exceeding the acceptable limit of 5%. Errors included incorrect nasal spray administration and unauthorized crushing of medications for residents with various medical conditions. Staff interviews confirmed the need to adhere to physician orders and facility policies.
The facility failed to ensure proper hand hygiene and kitchen cleanliness, leading to potential cross-contamination during meal service. Dietary staff were observed preparing food and assisting residents without washing hands or wearing gloves. Additionally, dust accumulation was noted on ceiling tiles and light fixtures above food prep areas, with uncovered food items placed below. Staff interviews confirmed that expectations for hygiene and cleanliness were not met.
The facility failed to follow enhanced barrier precautions and infection control procedures for several residents, including those with drug-resistant infections and indwelling medical devices. Staff did not consistently wear gowns and gloves during high-contact care, leading to potential infection risks. Interviews revealed confusion and non-compliance with established protocols.
The facility failed to perform and document required neuro checks following unwitnessed falls for two residents with cognitive impairments. Despite policy requirements, neuro checks were not consistently completed or recorded, leaving potential head injuries unassessed. Staff interviews confirmed the necessity of these checks, highlighting a lapse in adherence to professional standards.
The facility did not ensure pharmacist recommendations were reported and acted upon for two residents. A resident had a recommendation for a maximum dose warning for acetaminophen and oxycodone-acetaminophen, which was not addressed. Another resident had a recommendation for a gradual dose reduction of psychopharmacologic therapies, which was also not acted upon. Interviews revealed a lack of a follow-up system for these recommendations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 14.81% error rate during the survey. This was observed through four medication errors out of 27 opportunities, involving residents with various medical conditions. The errors included incorrect administration of nasal sprays and improper crushing of medications without physician orders. Resident #31, diagnosed with diabetes, depression, kidney disease, low thyroid hormone level, and stroke, received two sprays of fluticasone propionate in each nostril instead of the prescribed one spray. Resident #10, with elevated cholesterol, low thyroid hormones, and stroke, was administered only one drop of Deep Sea Nasal spray in each nostril instead of the prescribed two drops. Resident #12, with high cholesterol, depression, high blood pressure, seasonal allergies, and low thyroid hormone, had multiple medications crushed and administered together without orders for crushing, including lisinopril, citalopram, loratadine, and others. Additionally, Resident #88, diagnosed with high blood pressure, arthritis, anemia, anxiety, and high blood pressure, received acetaminophen 650 mg later than the scheduled time of 7:00 A.M. Interviews with staff, including a CMT, LPN, DON, and the Administrator, confirmed that medications should be administered as per physician orders and policies, and that crushing medications without orders is against the facility's procedures.
Deficiencies in Hand Hygiene and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper hand hygiene and cleanliness in the kitchen, leading to potential cross-contamination during meal service. Dietary Aide L was observed preparing food without gloves, assisting residents, and handling various items without performing hand hygiene between tasks. This included touching residents' utensils, picking up items from the floor, and checking food temperatures without washing hands or wearing gloves. Additionally, Dietary Aide M was seen wearing the same gloves while washing dishes and delivering food to residents, further contributing to the risk of cross-contamination. The facility also failed to maintain a clean kitchen environment, as evidenced by the accumulation of dust on ceiling tiles and light fixtures above food preparation areas. Observations on multiple days revealed dark dust buildup above the main food prep station and other areas, with uncovered food items placed below these dusty fixtures. Interviews with staff, including the Manager of Dining Services and the Director of Nursing, confirmed that the facility's expectations for hand hygiene and kitchen cleanliness were not met, as they acknowledged the need for frequent handwashing and a dust-free kitchen ceiling.
Failure to Follow Enhanced Barrier Precautions and Infection Control Procedures
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBPs) and infection control procedures, impacting several residents. For Resident #29, who had a history of Methicillin-resistant Staphylococcus infection and a positive urine culture for Vancomycin-resistant Enterococcus, staff did not wear gowns during high-contact activities such as transfers, despite the resident being on EBP. Observations showed that staff members only donned gloves, and there was a misunderstanding among staff about when gowns were required. Resident #40, who had a non-pressure related wound on the left lower leg and was on EBP, also experienced lapses in infection control. Staff entered the resident's room and provided care without wearing the required gowns and gloves. The resident confirmed that staff did not wear gowns during care, and there was no PPE available in or outside the resident's room. Interviews revealed confusion among staff about the resident's EBP status and the necessity of PPE during care. Resident #74, with a suprapubic urinary catheter, was also on EBP, yet staff provided perineal care and assisted with transfers without wearing gowns or gloves. Additionally, Resident #39 received care without proper hand hygiene or glove use by staff, further indicating a lack of adherence to infection control protocols. Interviews with staff, including the Infection Preventionist and Director of Nursing, highlighted expectations for PPE use during high-contact care, which were not met, leading to potential infection risks for all residents.
Failure to Complete Neuro Checks After Falls
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not completing neurological assessments following unwitnessed falls or falls where residents hit their heads. This deficiency was identified for two residents, both of whom had cognitive impairments and frequent falls. The facility's policy required neuro checks to be performed at specific intervals for 72 hours following such falls, but these checks were not consistently documented or completed. Resident #44, who had severe cognitive impairments and a history of falls, experienced multiple unwitnessed falls. Despite the facility's policy, neuro checks were not documented as completed for several intervals following these incidents. Similarly, Resident #35, who also had cognitive impairments and a history of falls, had neuro checks missing for several intervals after falls. Both residents were unable to reliably communicate what happened during their falls due to their cognitive status. Interviews with facility staff, including LPNs and the Director of Nurses, confirmed that neuro checks should have been initiated and documented following unwitnessed falls. The staff acknowledged that neuro checks are crucial for assessing potential head injuries, especially in residents who are confused and disoriented. However, the documentation in the electronic medical records did not reflect the completion of these checks as required by the facility's policy.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist reported any irregularities to the attending physician, Medical Director, and Director of Nursing, and did not ensure these reports were acted upon for two residents. Resident #47 had a recommendation from the consultant pharmacist regarding potential high dose therapy for acetaminophen and oxycodone-acetaminophen, suggesting a maximum dose warning be added to the Medication Administration Record. However, there was no record that this recommendation was addressed, and the physician's orders did not reflect any changes in the medications. Similarly, Resident #52 had a recommendation for a gradual dose reduction of psychopharmacologic therapies, specifically for escitalopram and mirtazapine, as required by federal nursing facility regulations. Again, there was no record that this recommendation was addressed, and the physician's orders remained unchanged. Interviews with facility staff revealed that the Medication Management Review reports were expected to be addressed within a week, but there was no system in place to follow up on these recommendations, leading to the deficiency.
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 986 citations issued within 25 miles in the last 12 months — including the 25 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Webster Groves
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary, Queen And Mother Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Oak Park Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Barnes-jewish Extended Care | 3 mi | ★★★★★ | 15 | 0 |
| Bethesda Dilworth | 3.3 mi | ★★★★★ | 2 | 0 |
| Lansdowne Village | 3.4 mi | ★★★★★ | 18 | 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.