Below 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 Nazareth Living Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, prior knee replacement with hardware, and dependence on staff for transfers repeatedly complained of right leg pain over several days, with CNAs observing screaming, a slanted-appearing leg, and increasing swelling, but without documented nursing assessment of the leg at that time. The resident, who was supposed to be a Hoyer lift transfer, continued to be moved by staff using various manual methods, including being picked up and placed in a recliner and treated at times as a 1–2 person assist. On one day, a CNA propelled the resident in a wheelchair without footrests, during which the resident’s right leg dragged and the resident screamed, and an LPN later noted swelling and pain before placing the feet on pedals and allowing the resident to continue in the chair. Later that day, the resident’s family member and staff performed a stand-pivot transfer from wheelchair to bed without a mechanical lift, with the family member lifting the resident’s legs into bed and the resident expressing discomfort. An x-ray subsequently showed an age-indeterminate distal femur fracture around the existing hardware, and the resident was sent to the ER for further evaluation.
Two residents did not receive care and medications as ordered by their providers. One resident with vascular disease and multiple chronic wounds had a physician order for daily and PRN left heel wound care with Aquacel AG, but documentation showed multiple missed treatments on days the resident was at dialysis, with no evidence the treatments were completed on other shifts, and staff later observed dressings left unchanged for several days. Another resident with multiple diagnoses had a standing order for daily levothyroxine, yet the MAR reflected numerous missed doses, with only a few omissions documented in progress notes and no explanation for the remaining missed administrations; an LPN reported the medication was not available and assumed it had been ordered. The DON and physician/Medical Director each stated they expected staff to follow physician orders and report missed treatments and medications.
A van driver transported two wheelchair-bound residents in a medical van equipped with only six straps, contrary to facility policy requiring eight straps for two wheelchairs. During the trip, one resident's wheelchair flipped backward, resulting in a fall and a closed head injury. The resident had a history of spinal stenosis, anxiety, depression, and was at risk for falls, requiring total assistance for transfers.
A resident with Alzheimer's disease and osteoporosis developed a large bruise and abrasion on the forehead after overturning a meal tray, but staff failed to immediately report or document the incident. The injury was only discovered and reported by a hospice worker, leading to delayed assessment, care, and required notifications to the family and physician. No vital signs or neurological checks were performed during the critical period following the injury, and staff interviews confirmed a lack of communication and documentation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
The facility did not ensure that its services met professional standards of quality, as identified through observations and review of practices. The report does not provide additional details about the specific actions or omissions that led to this deficiency.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A facility failed to obtain daily weights for a resident with congestive heart failure, as ordered by the physician. The resident's treatment administration record showed missing weight documentation on multiple dates, despite instructions to weigh daily and report significant weight gains. The Interim DON and Administrator confirmed that staff are responsible for following physician's orders, including documenting weights.
Failure to Use Safe Transfer Techniques and Wheelchair Footrests Resulting in Femur Fracture Concern
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and prevent accident hazards for a cognitively impaired resident with a history of knee replacement and hardware in the distal femur. The resident’s quarterly MDS showed severe cognitive impairment, dependence on staff for most ADLs, use of a wheelchair for mobility, and a need for substantial/maximal assistance with most transfers, including sit-to-stand and chair/bed transfers. The care plan identified a problem of falls and unsteady gait and directed staff to transfer the resident with a gait belt and assist of one staff. As early as 1/28, a CNA reported that the resident was complaining of leg pain, screaming, and holding or pointing to the leg, and noted the leg appeared slanted. The CNA reported these symptoms to the nurse on duty and a PT was consulted, who observed the resident yell out when the leg was moved and then provided elevating leg rests; however, there was no documentation in the medical record that the resident was assessed for injury at that time. Over the following days, multiple CNAs noted the resident’s complaints of pain and resistance to movement. One CNA reported that on 1/31 the resident said “ow” and did not like the leg moved, and that this was reported to the charge nurse, who said they would check on the resident. Another CNA stated that the resident’s leg pain continued into the next week, with the resident screaming louder and with more swelling by the time of the next shift worked. Despite these ongoing complaints and observable changes, the resident continued to be moved and transferred, including by staff who sometimes picked the resident up and placed the resident in a recliner, and by staff who believed the resident could be a 1–2 person assist, even though the resident was supposed to be a Hoyer lift transfer. The medical record did not contain documentation of a fall in the month prior to the acute evaluation, and there was no documented nursing assessment of the leg after the initial complaints on 1/28. On 2/1, the resident was observed being propelled in a wheelchair without foot pedals by a CNA. The resident screamed while being pushed down the hallway, and an LPN responding to the scream noted that the wheelchair had no foot pedals and that the resident’s right leg was dragging. The LPN observed some swelling and that the resident screamed when the leg was first touched, then laughed and denied further pain after the foot pedals were applied. The resident was then taken to meals and remained in the wheelchair. Later that day, the resident’s family member, who acknowledged that the resident required a two-person Hoyer lift, independently attempted to transfer the resident using a gait belt and then participated with staff in a stand-pivot transfer from wheelchair to bed without using a mechanical lift. During this transfer, the family member grabbed the resident’s ankles and lifted the legs into bed, and the resident expressed discomfort. Subsequent provider evaluation and x-ray revealed an age-indeterminate distal femur fracture around the area of the existing hardware, with severe pain, swelling, and deformity of the right knee noted, and the resident was sent to the emergency room for further evaluation and treatment. The facility later identified the lack of foot pedals during wheelchair propulsion and the improper transfer without a Hoyer lift as contributing factors to the incident.
Failure to Administer Ordered Wound Care and Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure treatments and medications were administered as ordered for two residents. For one resident with diabetes, hypertension, peripheral vascular disease, and multiple chronic wounds, the care plan called for wound treatments per physician orders and weekly skin assessments. A physician order directed daily and PRN cleansing of the left heel with wound cleanser, application of Aquacel AG, and coverage with foam dressing. The treatment administration record (TAR) showed that on multiple days the wound treatment was not completed because the resident was at dialysis, and there was no documentation that these missed treatments were completed on another shift. Progress notes from the same period contained no documentation regarding the wound treatment, and a wound care company later noted a dressing dated several days earlier on the left heel. Further observations showed that when the LPN removed the left heel dressing, the wound measured approximately 3.0 by 5.0 cm with a red and yellow base, and the LPN reported finding the dressing unchanged at times, despite orders for daily treatment. The TAR continued to show additional missed treatments on days the resident was at dialysis, again without documentation that the treatments were completed later. An MRI subsequently confirmed osteomyelitis of the left heel, and the resident was sent to the emergency room based on those results. The DON, physician/Medical Director, and Administrator each stated they expected staff to complete dressing changes and orders as written, and the DON reported she was unaware that treatments were not being completed as ordered. For a second resident with diagnoses including hypertension, anxiety, and depression, a physician order required levothyroxine 175 mcg to be administered every morning at 6:00 A.M. The medication administration record (MAR) for the month showed numerous days when the levothyroxine was not administered. Progress notes documented that the levothyroxine was not given on at least two specific dates and that the physician and family were aware, but there was no further documentation addressing the other missed doses. An LPN working night shift acknowledged awareness that the levothyroxine was not available and could not explain why, stating that medications are usually ordered by the day-shift CMT and assuming the medication was on order. The DON stated she expected staff to notify her when medications could not be obtained and to notify the family and physician each time a medication was missed, and the physician/Medical Director stated she expected to be notified when an ordered medication was not received.
Failure to Properly Secure Wheelchair Residents During Transportation
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards during resident transportation when a van driver transported two wheelchair-bound residents in a facility medical van that was only equipped with six straps, despite facility policy requiring eight straps to safely secure two wheelchairs. The van driver made the decision to transport both residents at the same time to prevent them from being late for their appointments, and while driving, one resident's wheelchair flipped backward after a turn, resulting in the resident falling. The van driver stopped, checked on the resident, repositioned them, and returned to the facility. The resident involved had a history of spinal stenosis, anxiety, depression, and required total assistance for transfers, with a documented risk for falls. After the incident, the resident complained of head and neck pain and was transported to the hospital, where a closed head injury was diagnosed. The facility's Executive Director was unaware of the van's strap limitations prior to the incident. The facility's Fleet Safety Program policy required proper securing of residents during transport, but this was not followed, leading to the accident.
Failure to Timely Report and Assess Resident Head Injury
Penalty
Summary
Facility staff failed to provide care consistent with professional standards when they did not immediately report a large bruise and abrasion to a resident's head, resulting in delayed assessment, care, and required notifications to the family and physician. The resident, who had diagnoses including Alzheimer's disease and osteoporosis, was found with a significant knot and bruising on the forehead, as well as a small cut. The incident was first noticed by a hospice worker, who observed dried blood on the resident's pillow and bed rail, and subsequently reported it to nursing staff. Upon assessment, the nurse practitioner and family were notified, but this occurred only after the hospice worker's intervention. Review of documentation and staff interviews revealed that a CNA had been feeding the resident the previous day when the resident overturned a tray onto themselves. The CNA cleaned the resident and the room but did not report the incident, believing it was not significant. The following morning, the same CNA noticed the injury but again did not report it, assuming someone else had already done so. There was no documentation of the incident or injury in the medical record prior to the hospice worker's report, and no vital signs or neurological checks were recorded during the critical period following the injury. Interviews with nursing staff and facility leadership confirmed that the injury was not communicated during shift change, and no assessments or documentation were completed until after the hospice worker's report. The Director of Nursing and Administrator both stated that staff are expected to report all injuries immediately and document them, but this did not occur in this case, resulting in a delay in assessment and care for the resident.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, were not provided in the report. The report notes a general failure to meet professional standards but does not include further factual observations or events related to the deficiency.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Obtain Daily Weights for Resident with Heart Failure
Penalty
Summary
The facility failed to ensure that daily weights were obtained as ordered for a resident with congestive heart failure. The resident was discharged from the hospital with instructions to weigh daily and contact the physician if there was a significant weight gain. The resident's admission Minimum Data Set indicated a history of weight loss and a physician's weight loss program. However, the resident's treatment administration record showed missing documentation of weights on several dates. During an interview, the Interim Director of Nursing and the Administrator acknowledged that staff are expected to follow physician's orders, including weighing residents and documenting weights in the medical record.
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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) |
|---|---|---|---|---|
| Bethesda Southgate | 2.1 mi | ★★★★★ | 0 | 0 |
| Bluebird Wellness And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
| Sherbrooke Village | 3.3 mi | ★★★★★ | 6 | 0 |
| Delmar Gardens South | 3.9 mi | ★★★★★ | 0 | 0 |
| Lemay Nursing | 4 mi | ★★★★★ | 0 | 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.