Nazareth Living Center
#2 Nazareth Lane, Saint Louis, MO 63129 · St. Louis County · 121 certified beds · avg 93 residents/day · certified since May 1, 1996
Part of chain: BENEDICTINE HEALTH SYSTEM (23 facilities, chain avg rating 2.8★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$11,928
Fines, last 3 years
3.83
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 29, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 2, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 26, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 29, 2023 (Past Non-Compliance)
All citations in the current public record (49)
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 5, 2026 | 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 8, 2026 | 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. · from a complaint |
| Dec 16, 2025 | 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 |
| Nov 17, 2025 | 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. · from a complaint |
| Jul 29, 2025 | ▲ G · Actual 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. · from a complaint |
| Jul 29, 2025 | E · Potential for harm, repeated | 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 |
| Jul 29, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Mar 14, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 14, 2025 | E · Potential for harm, repeated | 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. |
| Mar 14, 2025 | 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Mar 14, 2025 | D · Potential for harm, one-off | 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. |
| Mar 14, 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | 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. |
| Mar 14, 2025 | 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 14, 2025 | 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Mar 14, 2025 | B · Minimal risk, repeated | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Jul 24, 2024 | 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 |
| Oct 26, 2023 | ▲ G · Actual 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 |
| Oct 26, 2023 | F · Potential for harm, facility-wide | 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. |
| Oct 26, 2023 | E · Potential for harm, repeated | 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. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 26, 2023 | E · Potential for harm, repeated | 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. |
| Oct 26, 2023 | 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. |
| Oct 26, 2023 | D · Potential for harm, one-off | 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. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 26, 2023 | 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. |
| Oct 26, 2023 | C · Minimal risk, facility-wide | 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. |
| Oct 9, 2020 | E · Potential for harm, repeated | 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. |
| Oct 9, 2020 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | D · Potential for harm, one-off | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
| Oct 9, 2020 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (11 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2020 | 12 | 0 | E |
| 2023 | 11 | 1 | G ▲ |
| 2024 | 1 | 0 | D |
| 2025 | 23 | 1 | G ▲ |
| 2026 | 2 | 0 | D |
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)
1 fine totaling $11,928, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 14, 2025 | Payment Denial | 4 days from Jun 14, 2025 |
| Oct 26, 2023 | Fine | $11,928 |
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) | 3.83 | 3.66 | 3.95 | top 40% in Missouri; top 47% in the U.S. |
| Registered Nurse hours | 0.33 | 0.49 | 0.69 | bottom 32% in Missouri; bottom 12% in the U.S. |
| Weekend total nurse staffing | 3.43 | 3.22 | 3.50 | top 37% in Missouri; top 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.33 | 0.48 | bottom 23% in Missouri; bottom 10% in the U.S. |
| Total nursing staff turnover (%) | 77.4 | 56.0 | 45.8 | bottom 6% in Missouri; bottom 3% in the U.S. |
| RN turnover (%) | 85.7 | 47.8 | 42.9 | bottom 6% in Missouri; bottom 3% 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 3.69, RN 0.31, weekend 3.30. 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: 1/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sisters of St Joseph of Carondelet St Louis Province | Organization | 5% or Greater Direct Ownership Interest | 50% | 07/01/2009 |
| Benedictine Health System | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2009 |
| Bergien, Tricia | Individual | Corporate Officer | NOT APPLICABLE | 08/23/2017 |
| Bruhn, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Carley, Gerald | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/18/2017 |
| Collins, Julie | Individual | Contracted Managing Employee | NOT APPLICABLE | 08/09/2021 |
| Deblois, Beverly | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Essig, Leonard | Individual | Corporate Director | NOT APPLICABLE | 06/30/2014 |
| Hadican, Mary Kay | Individual | Corporate Director | NOT APPLICABLE | 06/30/2014 |
| Harris, Marie | Individual | Corporate Director | NOT APPLICABLE | 07/01/2015 |
| Haywood, Michael | Individual | Corporate Director | NOT APPLICABLE | 07/01/2017 |
| Hogan, Sean | Individual | Corporate Director | NOT APPLICABLE | 07/01/2019 |
| Ludwig, Robert | Individual | Corporate Director | NOT APPLICABLE | 06/30/2014 |
| Lutzeier, Fred | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Moore, Elaine | Individual | Corporate Director | NOT APPLICABLE | 10/01/2011 |
| Rapp, Deborah | Individual | Corporate Director | NOT APPLICABLE | 07/01/2016 |
| Rymanowski, Kevin | Individual | Corporate Director | NOT APPLICABLE | 01/01/2011 |
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 do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "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 |
|---|---|---|---|---|---|
| Bethesda Southgate | 2.1 mi | Saint Louis, MO | ★★★★★ | 5/5 | |
| Bluebird Wellness and Rehabilitation | 2.6 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | |
| Sherbrooke Village | 3.3 mi | Saint Louis, MO | ★★☆☆☆ | 2/5 | |
| Delmar Gardens South | 3.9 mi | Saint Louis, MO | ★★★★☆ | 4/5 | |
| Lemay Nursing | 4.0 mi | Saint Louis, MO | ★★☆☆☆ | 3/5 | |
| Fountain Care at Sunset Hills | 4.8 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | |
| Friendship Village Sunset Hills | 5.1 mi | Saint Louis, MO | ★★★☆☆ | 3/5 | |
| Woodland Manor Nursing Center | 5.2 mi | Arnold, MO | ★★☆☆☆ | 4/5 | |
| Nexus at Columbia | 6.1 mi | Columbia, IL | ★☆☆☆☆ | 2/5 | |
| Mary, Queen and Mother Center | 6.2 mi | Shrewsbury, MO | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265636.