Amberwood Estates Nursing and Rehabilitation
5303 Bermuda Drive, Saint Louis, MO 63121 · St. Louis County · 115 certified beds · avg 82 residents/day · certified since Jun 7, 2001
2/5
Health inspection rating (on-site)
0
Serious findings on record
$13,409
Fines, last 3 years
0.72
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (66)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Feb 4, 2026 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 4, 2026 | D · Potential for harm, one-off | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Sep 9, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 1, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Nov 22, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 22, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 22, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Sep 19, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 19, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 18, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Apr 18, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 3, 2024 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jan 3, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 9, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 9, 2022 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 9, 2022 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 9, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (17 → 23).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 9 | 0 | F |
| 2024 | 31 | 0 | E |
| 2025 | 3 | 0 | E |
| 2026 | 23 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $13,409.
| Date | Type | Amount / length |
|---|---|---|
| Sep 25, 2023 | Fine | $3,882 |
| Sep 5, 2023 | Fine | $9,527 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 0.72 | 3.66 | 3.95 | bottom 1% in Missouri; bottom 1% in the U.S. |
| Registered Nurse hours | 0.14 | 0.49 | 0.69 | bottom 4% in Missouri; bottom 1% in the U.S. |
| Weekend total nurse staffing | 0.63 | 3.22 | 3.50 | bottom 1% in Missouri; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.11 | 0.33 | 0.48 | bottom 5% in Missouri; bottom 2% in the U.S. |
| Total nursing staff turnover (%) | 84.5 | 56.0 | 45.8 | bottom 1% in Missouri; bottom 2% in the U.S. |
| RN turnover (%) | 83.3 | 47.8 | 42.9 | bottom 9% in Missouri; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.71, RN 0.14, weekend 0.62. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Aleem, Gwendolyn | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Crocker, Anita | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Farmer, Erika | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Forvis Mazars LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Forvis Mazars LLP | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| GS Capital Funding LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 02/01/2025 |
| GS Capital Funding LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2025 |
| Lazar, Levi | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Maylack, Elizabeth | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Maylack, Elizabeth | Individual | ADP of the SNF | NOT APPLICABLE | 05/20/2025 |
| Mburu, Emmah | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/07/2025 |
| Neuberger, Isaac | Individual | Trustee of the SNF | NOT APPLICABLE | 02/01/2025 |
| Phifer, Mona | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Revach LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2025 |
| Rice, Cicely | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Smith, Demarcus | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Tait, Katherina | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Zidele, Boruch | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2025 |
| Zidele, Boruch | Individual | ADP of the SNF | NOT APPLICABLE | 05/20/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How are residents' personal funds handled here, and what records can families review?"
- "How do you manage residents' personal funds, and how often do families receive an accounting?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Heritage Care Center | 1.2 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Oak Knoll Skilled Nursing & Rehabilitation Center | 1.9 mi | Ferguson, MO | ★★☆☆☆ | 3/5 | |
| Arbor Hills Care & Rehab Center | 2.1 mi | Ferguson, MO | ★☆☆☆☆ | 1/5 | |
| Normandy Nursing Center | 2.3 mi | Saint Louis, MO | ★☆☆☆☆ | 2/5 | abuse |
| Estates of St Louis, LLC, the | 2.8 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | |
| St Johns Place | 3.0 mi | Saint Louis, MO | ★☆☆☆☆ | 2/5 | |
| Hillside Health Care Center | 3.1 mi | Saint Louis, MO | —/5 | abuseSFF | |
| U-City Forest Manor | 3.4 mi | Saint Louis, MO | ★☆☆☆☆ | 2/5 | |
| Monarch Springs Wellness & Rehabilitation | 4.1 mi | University City, MO | ★★☆☆☆ | 3/5 | |
| Crestwood Health Care Center | 4.2 mi | Florissant, MO | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
All facilities in Saint Louis →
Facility data as of CMS processing date 2026-08-01. CCN 265719.