Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Nhc Healthcare, Maryland Heights during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses sustained bruising around one eye during morning care, initially documented by nursing as resulting from hitting the face on a bedside dresser while being assisted to sit up and dress. During subsequent hospital evaluation and later conversations with facility staff, the resident reported that a nurse or night-shift staff member hit or punched him/her in the eye, providing a physical description of the alleged perpetrator, while at other times also stating he/she may have fallen. Staff interviews confirmed that these inconsistent but abuse-related statements were heard and relayed to nursing, and ER records indicated the event was treated as a possible assault and reported to the state by hospital staff. Despite a written policy requiring that any event involving possible hitting be treated as an abuse allegation and reported to DHSS within specified time frames, the Administrator and DON chose not to report the allegation, relying instead on their belief that the injury was accidental and that the resident’s description did not match any staff, resulting in a failure to notify state authorities of a suspected abuse incident.
Improper sanitizer levels were found at the 3-compartment sink, with test strips not showing the expected color for the required ppm range, and staff discussed using an inappropriate product as a sanitizer substitute. Staff also observed scoops left inside bulk food bins, including sugar, thickener, and bread crumbs, rather than stored in a sanitary manner as expected by the FNSM and DM.
Wound care services did not meet professional standards when staff failed to clarify conflicting wound orders for one resident and did not provide wound care as ordered for another resident. One resident with PVD/PAD, diabetes, stroke, and impaired cognition had multiple right toe wound orders in the chart, and an LPN said staff did not know which order was correct. Another resident with cancer, a-fib, PVD/PAD, and diabetes had a right shin skin tear, but the dressing was left on for two to three days despite an order for daily treatment, and there was no documentation of refusal or a hold on treatment.
Expired and undated medications and treatment supplies were found in multiple med rooms and med carts. Surveyors observed an expired rapid COVID-19 test, opened and undated OTC meds, expired eye drops, expired wound care supplies, and opened insulin pens that were either undated or past their opened expiration dates. Staff stated nurses and pharmacy staff were responsible for checking expiration dates, and the DON said insulin pens and OTC meds should be dated when opened.
The facility failed to provide a clean and homelike environment in the common area on the Ivy Hall and the resident rooms on the Meadow unit. Observations revealed soiled furniture, lack of toilet paper and hand towels, and missing toilet tank lids. Staff interviews indicated unawareness and improper stocking practices.
The facility failed to prevent potential injury while assisting a resident in a wheelchair, ensure a shower room floor was clear of trip hazards for a resident at risk of falls, and properly store chemicals on the memory care unit. Additionally, the facility did not take appropriate precautions to prevent slips and falls while floors were being mopped.
The facility failed to ensure that medications in 2 of 4 medication rooms and 2 of 7 medication/treatment carts were within expiration dates. Instances included an open multi-dose vial of Tubersol, a used Basaglar KwikPen, a Breo Ellipta inhaler, and a Soliqua injection pen without open dates. Staff interviews confirmed that medications should be dated when opened, but this was not consistently done.
The facility failed to ensure staff performed proper hand hygiene during meal service in the main dining room. Observations revealed that staff members, including CNAs and CMTs, did not wash or sanitize their hands after touching potentially contaminated surfaces and before assisting residents with meals. Interviews with staff confirmed that proper hand hygiene practices were expected but not followed.
The facility failed to follow cleaning protocols for a resident's BiPAP machine, leading to improper placement and lack of maintenance. Staff were unaware of specific cleaning instructions, and the care plan did not address the necessary cleaning procedures, risking potential respiratory infections.
The facility failed to ensure the quality of blood glucose test strips by not following the manufacturer's directions to date the containers when opened. Observations on two nurse carts showed containers without an open date, and the DON confirmed this practice.
Failure to Report Resident’s Allegation of Staff Physical Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy by not reporting an allegation of staff-to-resident physical abuse to the Department of Health and Senior Services (DHSS). The facility’s written policy, revised 2/1/23, states that any event reported to staff that might constitute abuse, including any instance of hitting, slapping, pinching, or kicking, must be treated as an allegation and reported within specified time frames. The policy also defines physical abuse as including hitting and requires that all allegations be immediately assessed and that patients be protected from harm during an investigation. Despite these requirements, the facility did not notify DHSS after a resident alleged that a staff member hit him/her in the eye. The resident involved had severe cognitive impairment per a quarterly MDS dated 12/26/25, with diagnoses including dementia, anxiety disorder, bipolar disorder, and schizophrenia, and was dependent in most ADLs with impairment of both lower extremities. On 3/30/26, nursing documentation indicated that the resident’s facial injury was attributed to the resident bumping his/her face on a dresser while being assisted to sit up and get dressed, resulting in a small red spot and a dark purple bruise under the right eye. The responsible party was notified and requested hospital evaluation. Hospital ER records later documented that the resident reported he/she may have been assaulted and that the incident was reported to the state by nursing. A subsequent NP note on 3/31/26 recorded that, while the initial explanation was a fall against the dresser, the resident told ER staff that a nurse punched him/her in the eye and later told facility staff that someone in a red hat or with red hair hit or poked him/her in the eye. Interviews and observations showed that the resident continued to state that a night shift staff member, described as a white female with short reddish-black hair with a red tint, hit him/her in the eye. Another staff member reported that the resident alternated between saying he/she fell and saying somebody hit him/her, and this was reported to a nurse. The DON acknowledged being told by staff on 4/1/26 that the resident had mentioned someone hitting him/her, and when the DON spoke with the resident at the surveyor’s request, the resident again stated that he/she was hit by a staff member and gave the same physical description. The Administrator and DON, however, stated they did not report the incident to DHSS because they believed they knew the cause of the bruising (contact with the dresser during care) and felt the resident’s description did not match any staff. They also acknowledged that the hospital had reported the matter to DHSS and that a police officer had come to the facility at the family’s care plan meeting, but no police report was filed. Despite multiple statements by the resident suggesting possible abuse and the facility’s knowledge that the hospital had treated it as a possible abuse allegation, the facility did not submit a facility-reported incident or otherwise notify DHSS, in direct conflict with its abuse reporting policy.
Improper Sanitizer Levels and Scoop Storage in Dietary Area
Penalty
Summary
The facility failed to ensure the three-compartment sink sanitizer levels were at the appropriate levels and failed to use an appropriate chemical as a substitute. During observation and interview, the Dietary Manager tested the sanitizing solution in the three-compartment sink with the facility’s test strips, and the strip changed from light blue to light yellow, but the ppm level was unknown because it did not show the expected color. The Dietary Manager stated the expected color was green to indicate approximately 700 ppm lactic acid or 272 ppm DDBSA. He also stated he would drain the sink water and use Dip It XP Concentrated Coffee and Tea De-Stainer as a sanitizer, while the facility’s connected sanitizer was Ecolab’s Solitaire Concentrated Solid Detergent. Review of the facility’s checklist showed the three-compartment sink sanitization was documented three times daily at 700 ppm lactic acid from 3/1/26 through 3/19/26, and the Ecolab test strip instructions identified the effective range and green color chart for sanitizer levels. The facility also failed to ensure dietary staff stored scoops in a sanitary manner when scoops were observed inside food product containers. Observations showed a large scoop inside the bulk sugar bin and a large scoop inside the thickener bin, and later a large scoop inside the bread crumb bin and another inside the thickener bin. During interview, the Food and Nutrition Services Manager and Dietary Manager stated scoops were expected to be hung inside the bin and should not be left inside thickener or breadcrumbs due to cross contamination. The Dietary Manager and Administrator both confirmed the expectation that scoops should be hooked inside the bins and that staff should respond appropriately when sanitizer testing did not show the appropriate level.
Wound care orders were not clarified and wound treatments were not provided as ordered
Penalty
Summary
The facility failed to ensure wound care services met professional standards when staff did not clarify conflicting wound treatment orders for Resident #140 and did not provide wound care exactly as ordered for Resident #195. The report states that five residents with wounds were reviewed in depth and issues were found with two. The facility policy required medications and treatments to be administered only upon written orders from a licensed prescriber. Resident #140 had moderately impaired cognition and diagnoses including PVD/PAD, diabetes, high cholesterol, stroke, and hemiplegia/hemiparesis. The resident’s care plan included wound care for the right toe, with orders for Aquacel Ag and Santyl, while a physician order dated 3/2/26 directed cleansing the wound on the right foot fourth metatarsal toe with wound cleanser, painting with betadine, and securing with a foam dressing. Additional orders dated 3/4/26 directed Santyl and Aquacel Ag with wound cleansing and dressing application. During observation, the wound nurse cleansed the wound, applied Santyl, and covered it with a dry dressing. During interview, an LPN stated the resident had three different treatment orders, that the treatment already completed was based on what appeared in the computer, and that staff did not know which order was correct. Resident #195 was cognitively intact and had diagnoses including cancer, a-fib, PVD/PAD, and diabetes. After the resident sustained a right shin skin tear, the physician ordered triple antibiotic ointment, Aquacel, and a dry dressing every shift until healed, then later changed the order to once daily until healed. On observation, the dressing on the right shin had the date 3/15/26, shift notation, and initials written on it, and the resident stated staff left the dressing on for two to three days before changing it, though he/she never refused treatment. The record contained no documentation that the resident refused treatment or that the treatment was on hold. An LPN stated the skin tear treatment was to be completed once a day, and the DON stated staff were expected to follow physician orders and clarify wound orders when more than one treatment order existed.
Expired and Undated Medications and Supplies Found in Medication Storage Areas
Penalty
Summary
Drugs and biologicals were not stored in accordance with acceptable standards of practice in multiple medication storage areas. The facility identified four medication rooms and eight medication/treatment carts, and surveyors checked two medication rooms and five medication/treatment carts. In both medication rooms and three medication/treatment carts, staff failed to remove expired medications and treatment supplies and failed to date opened insulin pens and over-the-counter medications. The facility’s Medication Storage policy stated that medications and biologicals must be stored safely and properly, outdated items must be removed from inventory and disposed of, and products requiring shortened expiration dates after opening must be dated by the nurse. At the Ivy Hall medication cart, surveyors found an open and expired BinaxNOW COVID-19 Antigen Self-Test, an opened and undated bottle of acetaminophen 325 mg, an opened and undated bottle of Senna tablets, an opened box of GenTeal Tears vials expired 2/2026, an opened and undated bottle of Chest Congestion Relief DM, and an opened and undated bottle of ProHeal Liquid Protein. In the 200 Hall medication room, a caddy contained two xeroform gauze pads that were cut in half, opened, and dried out, and the treatment cart contained an opened tube of Medihoney with expiration date 6/1/25, an opened tube of pain-relieving cream with expiration date 6/2025, and an IV start kit with expiration date 7/31/25. Surveyors also found an opened and undated insulin glargine pen on the 200 Hall medication cart, a Novolog insulin pen opened on 2/11/26 and expired on 3/15/26, a Fiasp FlexTouch insulin pen opened on 2/14/26 and expired on 3/16/26, an opened and undated acetaminophen 325 mg bottle on the 300 Hall medication cart, and two dressing kits expired on 10/31/25 in the 300 medication room. Staff interviewed stated nurses and pharmacy staff were responsible for checking expiration dates, and the DON stated medications and treatment supplies should be stored safely and securely and that insulin pens and OTC medications should be dated when opened.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment in the common area on the Ivy Hall and the resident rooms on the Meadow unit. Observations over several days revealed that the furniture in the common area, including four rocking recliners and a navy blue plaid couch, was visibly soiled with multiple layers of brown and white crusted stains and food crumbs. Residents were observed sitting on this soiled furniture. Interviews with staff indicated that they were unaware of the stains and acknowledged that the furniture was not acceptable and should be cleaned until new furniture arrived. Additionally, the facility failed to ensure that resident rooms on the Meadow unit were adequately supplied with toilet paper and hand towels. Multiple observations over several days showed that numerous rooms shared by residents had no toilet paper or hand towels, and some restrooms had urine or feces in the toilets and soiled briefs on the floor. Interviews with CNAs, housekeeping staff, and the Housekeeping Supervisor revealed that toilet paper and hand towels were not stocked in resident rooms due to concerns about residents flushing excessive toilet paper and clogging the toilets, as well as residents taking and hoarding these items. Furthermore, the facility failed to maintain toilets with all standard parts in the Meadow unit. Observations showed that several restrooms shared by residents had missing toilet tank lids. Interviews with housekeeping staff, CNAs, the Housekeeping Supervisor, and the Maintenance Director indicated that they were unaware of the missing lids and expected staff to report such issues to Maintenance. The Director of Nurses and Administrator confirmed that staff should report maintenance issues and that residents on the Meadow unit should be toileted in the shower room to prevent issues with toilet paper and hand towels.
Failure to Prevent Accident Hazards and Ensure Proper Chemical Storage
Penalty
Summary
The facility failed to ensure staff took appropriate precautions to prevent potential injury while assisting a resident in propelling their wheelchair. The resident, who had multiple diagnoses including Alzheimer's disease, vascular dementia, and hemiplegia, was observed being pushed in a wheelchair without footrests, causing their feet to drag on the floor. Staff interviews revealed that residents in wheelchairs should have their feet up on footrests when being assisted, and staff should explain procedures before beginning. However, this protocol was not followed, leading to potential injury for the resident. The facility also failed to ensure a shower room floor was clear of trip hazards for a resident at risk of falls. The resident, who had a history of falls and used a walker, was observed stumbling over a loose plastic bag on the shower room floor. Staff interviews confirmed that the shower room should be free from trip hazards and that soiled linens should be stored properly. However, the presence of the plastic bag on the floor posed a significant risk to the resident. Additionally, the facility failed to properly store chemicals on the Meadow memory care unit, where many residents exhibited wandering behavior. Chemicals such as Clorox Bleach Germicidal Wipes and Dermavera skin and hair cleanser were found in unlocked cabinets and resident rooms. Staff interviews indicated that all chemicals should be locked up to prevent access by residents. However, the failure to secure these chemicals exposed residents to potential harm. Furthermore, the facility did not take appropriate precautions to prevent slips and falls while floors were being mopped, as wet floor signs were not consistently used, and residents were observed walking on wet floors.
Failure to Ensure Medications Are Within Expiration Dates
Penalty
Summary
The facility failed to ensure that medications kept in the medication rooms and on medication carts were within the date of expiration. This deficiency was observed in 2 of 4 medication rooms and 2 of 7 medication/treatment carts checked. Specific instances included an open multi-dose vial of Tubersol without an open date in the 100 hall medication room, a used Basaglar KwikPen and a Breo Ellipta inhaler without open dates on the 100 hall medication cart, and an opened multidose vial of Humulin R without an open date in the 200 hall medication room. Additionally, a used Soliqua injection pen without an open date was found on the 400 hall medication cart, which had been discontinued but was still present on the cart. Interviews with staff, including an LPN and the Director of Nursing, confirmed that insulin pens and vials should be dated when opened to track expiration. The facility's policy on medication storage requires that medications be stored safely and securely, with outdated or deteriorated medications removed from inventory. However, the observations indicated that this policy was not consistently followed, leading to the presence of expired or potentially expired medications in the facility's medication storage areas.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during meal service in the main dining room. Multiple observations revealed that staff members, including CNAs and CMTs, did not wash or sanitize their hands after touching potentially contaminated surfaces and before assisting residents with meals. Specific instances included a CNA handling clothing protectors, wheelchairs, and cups without performing hand hygiene, and a CMT passing meal trays, drinks, and condiments without washing hands. Additionally, staff members were observed touching their hair and other surfaces before assisting residents with feeding, again without performing hand hygiene. During breakfast, a CNA was observed pouring drinks and then opening a trash can lid with their hands before returning to pour more drinks without washing their hands. Another CNA was seen assisting two residents with feeding, touching various items and the residents themselves without performing hand hygiene in between. These actions were in direct violation of the facility's infection control policies, which emphasize the importance of hand hygiene to prevent the spread of infectious diseases among vulnerable residents. Interviews with staff, including a dietary aide, a CNA, the dietary manager, and the administrator, confirmed that proper hand hygiene practices were expected during meal times. Staff acknowledged the importance of hand hygiene in preventing illness and stated that hand washing should be performed before, during, and after assisting residents. Despite this, the observations clearly showed a lack of adherence to these practices, leading to the identified deficiency.
Failure to Follow BiPAP Cleaning Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident using a BiPAP machine by not following the facility's policy and obtaining physician orders related to cleaning the equipment. The resident, who had severe cognitive impairment and multiple health conditions including heart failure, end-stage renal disease, and obstructive sleep apnea, was observed with the BiPAP mask, headgear, and tubing improperly placed on the floor and bed. The care plan did not address the cleaning or maintenance of the BiPAP machine, and there were no physician orders for such cleaning in the resident's records. Interviews with staff revealed a lack of awareness and adherence to the cleaning protocols for the BiPAP machine. One LPN was unaware of any special cleaning instructions and suggested reaching out to the resident's family for guidance. Another LPN acknowledged the necessity of cleaning the BiPAP equipment to prevent infections but noted the absence of specific orders. The Director of Nursing confirmed that the nursing staff was expected to clean the BiPAP machine, mask, and tubing according to policy or manufacturer's instructions to prevent respiratory infections.
Failure to Ensure Quality of Blood Glucose Test Strips
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of the residents by not ensuring the quality of blood glucose test strips. Specifically, staff did not follow the manufacturer's directions to write the opening date on the vial label and discard remaining strips after 90 days. Observations on two different nurse carts revealed containers of blood glucose check strips without an open date. During an interview, the Director of Nursing confirmed that the containers should be dated when opened.
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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 Maryland Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Maryland Heights | 0.8 mi | ★★★★★ | 4 | 0 |
| River Crossing Rehab And Healthcare Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Parkwood Skilled Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 7 | 0 |
| Avenir At Mark Twain | 1.6 mi | ★★★★★ | 40 | 0 |
| Bentleys Extended Care | 1.8 mi | ★★★★★ | 8 | 0 |
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