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CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
Surrey Place St. Luke’s Hospital Skilled Nursing is a 130-bed skilled nursing facility at 14701 Olive Blvd, Chesterfield, Missouri, in St. Louis County, operated by St. Luke’s Episcopal-Presbyterian Hospital and administered by Tracy Imhoff.
The facility accepts Medicare, Medicaid, and private-pay residents and holds CMS certification number 265414.
A serious medication error occurred during a September 11, 2024 complaint investigation. This deficiency was cited as a failure to ensure residents were free from significant medication errors and resulted in a moderate citation marked as corrected. Prior to this incident, an August 1, 2024 health inspection found deficiencies in infection control and in the absence of a water system management program to prevent Legionella growth. A December 2022 inspection documented failure to assist a resident with grooming and personal hygiene.
RNs provide 1 hour 50 minutes per resident daily (293% above Missouri’s 28-minute state average); LPNs deliver 1 hour 10 minutes daily (71% above state average); CNAs provide 2 hours 24 minutes daily (4% above state average). Weekend nursing totals 4 hours 29 minutes per resident per day, 47% above the Missouri state average. Physical therapy staffing is unusually comprehensive at 17 minutes per resident daily (751% above state average). RN weekend coverage specifically is 1 hour 6 minutes daily, 230% above state average.
Long-stay residents experienced zero falls with major injury (100% better than state baseline), zero urinary tract infections (100% better), and pneumococcal vaccination rates of 100% (17% better than state). Functional decline for long-stay residents is 1.7 (91% better than state). However, two quality metrics are concerning: long-stay residents with pressure ulcers stand at 9.1% (81% worse than Missouri’s 5% average), and weight loss in long-stay residents is documented at 25% (349% worse than Missouri’s 5.6% baseline). Short-stay re-hospitalization is 27.5% (9% worse than state average of 25.3%), and ability to care for self at discharge is 40.3% (25% worse than state’s 53.7%).
The CMS overall rating is 3 stars (14.1% above state average). Health Inspection rating is 2 stars (31% below state average). Staffing receives 5 stars (131.5% above state average). Quality Measures are rated 4 stars (43.4% above state average).
The facility received designation as Best Nursing Home 2026 by U.S. News and World Report and America’s Best Nursing Homes 2025 by Newsweek.
Inspection history since 2019 includes four health inspections with 16 total citations (4 citations per inspection, compared to Missouri average of 5.67). Zero citations are critical or serious severity. Of 16 citations, 15 are moderate and 1 is minor. No federal penalties have been imposed in the past three years.
Current occupancy is approximately 62% (80 residents in 130 beds). The facility is located less than 3 miles from St. Luke’s Hospital. Walk score is 39, indicating the neighborhood is somewhat walkable with most trips requiring transportation.
Families should ask about corrective measures implemented following the September 2024 medication allergy management failure, specifically regarding how the facility now documents allergy severity.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 18th out of 276 homes in Missouri for nurse hours. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 2h 22m per day | ▲ 407% State avg: 28m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 1h 15m per day | ▲ 84% State avg: 41m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 24m per day | ▲ 4% State avg: 2h 19m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 5h 8m per day | ▲ 69% State avg: 3h 3m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 19m per day | ▲ 832% State avg: 2m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 1h 19m per day | ▲ 294% State avg: 20m per day · National avg: 28m per day |
Higher than the Missouri average: 66.6%Surrey Place St Luke’s Hospital Skilled Nursing is legally operated by St Lukes Episcopal Presbyterian Hospital, and administrated by Brent Glover.
In Missouri, the Department of Health and Senior Services, Division of Regulation and Licensure performs the inspections and unannounced surveys required for all long-term care providers.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Missouri state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | MO Average | vs. MO Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 56 | 35 | This facility has 60% more total deficiencies than a typical Missouri nursing home (56 vs. MO avg 35).↑ 60% worse |
|
Deficiencies per year
Average deficiencies per year since 2018.
| 7 | 4.4 | This facility has 59% more deficiencies per year than a typical Missouri nursing home (7 vs. MO avg 4.4).↑ 59% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 4.7 | 5 | This facility has 6% fewer deficiencies per inspection than a typical Missouri nursing home (4.7 vs. MO avg 5).↓ 6% better |
Inspections
| This Facility | MO Average | vs. MO Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
| 12 | 7 | This facility has 71% more total inspections than a typical Missouri nursing home (12 vs. MO avg 7).↑ 71% worse |
Missouri average 6.6
Last Health inspection on Sep 2024
Missouri average 36.5
Missouri average 5.67
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
11 of 16 citations resulted from standard inspections; 1 of 16 resulted from complaint investigations; and 4 of 16 came from combined inspections (standard and complaint).
100% better than Missouri averageMissouri average: 0.7
100% better than Missouri averageMissouri average: 1
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
35% more staff per resident than Missouri average
11% worse than Missouri average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 32 RN Staff are full-time employees. No contractors work on this role.
32
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.5 hoursAssists with medical care and medications.
All 28 LPN Staff are full-time employees. No contractors work on this role.
28
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.7 hoursHelps with daily care and mobility.
All 55 CNA Staff are full-time employees. No contractors work on this role.
55
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.8 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
304 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 55 | 0 | 55 | 10,478 | 92 | 100% | 6.8 |
| Registered Nurse | 32 | 0 | 32 | 8,831 | 92 | 100% | 8.5 |
| Licensed Practical Nurse | 28 | 0 | 28 | 5,402 | 92 | 100% | 6.7 |
| Clinical Nurse Specialist | 6 | 0 | 6 | 2,167 | 67 | 73% | 8.1 |
| Physical Therapy Aide | 9 | 0 | 9 | 1,884 | 78 | 85% | 7.1 |
| Speech Language Pathologist | 7 | 0 | 7 | 1,872 | 77 | 84% | 7.1 |
| Respiratory Therapy Technician | 9 | 0 | 9 | 1,488 | 76 | 83% | 7.2 |
| Mental Health Service Worker | 4 | 0 | 4 | 1,117 | 78 | 85% | 8.3 |
| Qualified Social Worker | 7 | 0 | 7 | 1,035 | 77 | 84% | 6.7 |
| Medication Aide/Technician | 7 | 0 | 7 | 1,029 | 75 | 82% | 9 |
| Physical Therapy Assistant | 6 | 0 | 6 | 772 | 77 | 84% | 6.8 |
| Other Social Services Staff | 3 | 0 | 3 | 756 | 86 | 93% | 5.3 |
| RN Director of Nursing | 2 | 0 | 2 | 613 | 65 | 71% | 5.5 |
| Administrator | 1 | 1 | 2 | 586 | 64 | 70% | 6.6 |
| Nurse Practitioner | 1 | 0 | 1 | 359 | 52 | 57% | 6.9 |
| Occupational Therapy Aide | 1 | 0 | 1 | 323 | 63 | 68% | 5.1 |
| Dietitian | 1 | 0 | 1 | 223 | 44 | 48% | 5.1 |
| Occupational Therapy Assistant | 1 | 0 | 1 | 165 | 27 | 29% | 6.1 |
| Medical Director | 1 | 0 | 1 | 37 | 20 | 22% | 1.9 |
| Nurse Aide in Training | 1 | 0 | 1 | 26 | 2 | 2% | 13.2 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
8.5
22% better than Missouri averageMissouri average: 10.9
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
1.7
91% better than Missouri averageMissouri average: 19.5
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
0.0%
100% better than Missouri averageMissouri average: 19.8%
Percent of low risk long-stay residents who lose control of their bowels or bladder
3.4%
81% better than Missouri averageMissouri average: 18.1%
Percent of long-stay residents experiencing one or more falls with major injury
0.0%
100% better than Missouri averageMissouri average: 4.0%
Percent of long-stay high risk residents with pressure ulcers
9.1%
81% worse than Missouri averageMissouri average: 5.0%
Percent of long-stay residents with a urinary tract infection
0.0%
100% better than Missouri averageMissouri average: 2.7%
Percent of long-stay residents who lose too much weight
25.0%
349% worse than Missouri averageMissouri average: 5.6%
Percent of long-stay residents who have depressive symptoms
0.0%
100% better than Missouri averageMissouri average: 12.8%
Percent of long-stay residents who received an antipsychotic medication
18.8%
15% better than Missouri averageMissouri average: 22.0%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
100.0%
17% better than Missouri averageMissouri average: 85.2%
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
99.6%
50% better than Missouri averageMissouri average: 66.6%
Percent of short-stay residents who newly received an antipsychotic medication
0.2%
91% better than Missouri averageMissouri average: 2.2%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
97.5%
54% better than Missouri averageMissouri average: 63.5%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
27.5%
9% worse than Missouri averageMissouri average: 25.3%
Percentage of short-stay residents who had an outpatient emergency department visit.
11.9%
11% better than Missouri averageMissouri average: 13.4%
Percentage of SNF residents who experience falls with major injury during their stay.
0.7%
12% better than Missouri averageMissouri average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
40.3%
25% worse than Missouri averageMissouri average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
59.3%
17% better than Missouri averageMissouri average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
80Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
0.0 miles from city center
Estimated distance in miles from Chesterfield's city center to Surrey Place St Luke’s Hospital Skilled Nursing's address, calculated via Google Maps.
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Surrey Place St Luke’s Hospital Skilled Nursing is located in CHESTERFIELD, Missouri.
Here are the financial assistance programs available to residents in Missouri.
The information below is reported by the Missouri Department of Health and Senior Services, Division of Regulation and Licensure.
| Garden View Care Center of Chesterfield |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
HC Home Care Professional care delivered in the person's own home — from companionship and errands to skilled nursing and therapy. Allows seniors to age in place. Medicare covers skilled home health when medically necessary.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk.
RC Respite Care Short-term temporary care — days to weeks — to give family caregivers a break. Full care provided during the stay. Often used after hospitalization or to trial a facility before a permanent placement decision. | Chesterfield (Lucas Pond) | 52
Facility
52
MO AVG
97
Rank
#384 / 454 |
58.7%
Facility
58.7%
MO AVG
66.6%
Rank
#278 / 428 | -12% | 5.23
Facility
5.23
MO AVG
3.74
Rank
#20 / 276 | +21% | +40% | $0
Facility
$0
MO AVG
$76.9k
Rank
#1 / 283 | 20
Facility
20
MO AVG
36.5
Rank
#74 / 281 | 4.0
Facility
4.0
MO AVG
5.7
Rank
#75 / 281 | - | 44 |
19
Facility
19
MO AVG
45
Rank
#456 / 563 | Jodi Luaders | $8.5M
Facility
$8.5M
MO AVG
$8.4M
Rank
#94 / 286 | $4.5M
Facility
$4.5M
MO AVG
$3.3M
Rank
#100 / 286 | 52.8%
Facility
52.8%
MO AVG
45.6%
Rank
#161 / 286 | 265627 | ||||
| Surrey Place St Luke’s Hospital Skilled Nursing |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Chesterfield | 130
Facility
130
MO AVG
97
Rank
#76 / 454 |
100.0%
Facility
100.0%
MO AVG
66.6%
Rank
#255 / 428 | +50% | 5.27
Facility
5.27
MO AVG
3.74
Rank
#18 / 276 | +127% | +41% | $0
Facility
$0
MO AVG
$76.9k
Rank
#1 / 283 | 16
Facility
16
MO AVG
36.5
Rank
#55 / 281 | 4.0
Facility
4.0
MO AVG
5.7
Rank
#75 / 281 | - | 159 |
39
Facility
39
MO AVG
45
Rank
#329 / 563 | St Lukes Episcopal Presbyterian Hospital | - | - | - | 265414 | ||||
| Delmar Gardens of Chesterfield |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk.
RC Respite Care Short-term temporary care — days to weeks — to give family caregivers a break. Full care provided during the stay. Often used after hospitalization or to trial a facility before a permanent placement decision. | Chesterfield (Walnut Hill Plaza) | 237
Facility
237
MO AVG
97
Rank
#5 / 454 |
76.4%
Facility
76.4%
MO AVG
66.6%
Rank
#139 / 428 | +15% | 4.58
Facility
4.58
MO AVG
3.74
Rank
#43 / 276 | -62% | +23% | $17.2k
Facility
$17.2k
MO AVG
$76.9k
Rank
#192 / 283 | 42
Facility
42
MO AVG
36.5
Rank
#191 / 281 | 8.4
Facility
8.4
MO AVG
5.7
Rank
#254 / 281 | 1 | 172 |
36
Facility
36
MO AVG
45
Rank
#350 / 563 | Kavitha Nallabelli | $26.1M
Facility
$26.1M
MO AVG
$8.4M
Rank
#12 / 286 | $11.0M
Facility
$11.0M
MO AVG
$3.3M
Rank
#8 / 286 | 42.4%
Facility
42.4%
MO AVG
45.6%
Rank
#246 / 286 | 265170 |
The legal owner and operator of Surrey Place St Luke’s Hospital Skilled Nursing is St Lukes Episcopal Presbyterian Hospital.
Surrey Place St Luke’s Hospital Skilled Nursing has a walk score of 39. Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
According to MO state health department records, Surrey Place St Luke’s Hospital Skilled Nursing's license number is 052456.
According to MO state health department records, Surrey Place St Luke’s Hospital Skilled Nursing's license expires on January 29, 2027.
Surrey Place St Luke’s Hospital Skilled Nursing's occupancy is 100%.
Brent Glover is the administrator of Surrey Place St Luke’s Hospital Skilled Nursing.
Surrey Place St Luke’s Hospital Skilled Nursing has 130 beds.
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