Map showing the location of AMBERWOOD ESTATES NURSING AND REHABILITATION in SAINT LOUIS, Missouri
5303 BERMUDA DRIVE, SAINT LOUIS, MO, 63121

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MissouriLowest tier among peers479 rated homes · average 2.5★
  • St. Louis CountyLowest tier among peers69 rated homes · average 2.3★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs MO avg
  • StaffingCan add or remove a star1★−1.1 vs MO avg
  • Quality measuresCan add or remove a star1★−1.7 vs MO avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersMO avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersMO avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersMO avg2.7★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.93hrsAbove only 21% of peersMO avg3.47Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.09hrsAbove only 1% of peersMO avg0.46Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better84%Above only 4% of peersMO avg57%RN turnover100%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$22,934Above only 31% of peersMO avg$37,310Fines · denials4 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
72citations
14inspection dates
0actual harm (G–I)
1immediate jeopardy (J–L)
Sep 9, 2025most recent

Citations by monthFeb 2022 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 9, 20251 citationCycle 1worst E · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Sep 19, 2025
Aug 6, 20251 citationCycle 1worst D · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 7, 2025
May 1, 20251 citationCycle 1worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jun 10, 2025
Nov 22, 20243 citationsCycle 2worst E · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 9, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 9, 2024
  3. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Dec 9, 2024
Sep 19, 20246 citationsCycle 2worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 9, 2024
  2. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 9, 2024
  3. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Dec 9, 2024
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 2, 2024
  5. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 2, 2024
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Nov 2, 2024
Apr 18, 202417 citationsCycle 1worst E · no actual harm
  1. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 28, 2024
  2. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected May 28, 2024
  3. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected May 30, 2024
  4. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 28, 2024
  5. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected May 28, 2024
  6. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected May 30, 2024
  7. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 28, 2024
  8. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected May 30, 2024
  9. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected May 28, 2024
  10. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 28, 2024
  11. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 30, 2024
  12. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 28, 2024
  13. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsE · patternCorrected May 28, 2024
  14. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected May 28, 2024
  15. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected May 28, 2024
  16. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 30, 2024
  17. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 28, 2024
Feb 9, 20242 citationsCycle 2worst D · no actual harm
  1. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 21, 2024
Jan 3, 20243 citationsCycle 3worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 30, 2023
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jan 29, 2024
  3. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Jan 29, 2024
Jul 31, 20231 citationCycle 3worst E · no actual harm$6,351
  1. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsE · patternCorrected Aug 14, 2023
Jun 9, 20234 citationsCycle 3worst E · no actual harm
  1. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsE · patternCorrected Aug 14, 2023
  2. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Jul 19, 2023
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 19, 2023
  4. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Jul 19, 2023
Mar 24, 20233 citationsCycle 3worst J · immediate jeopardy
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Feb 17, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 13, 2023
  3. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Apr 13, 2023
Feb 9, 20232 citationsCycle 3worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 3, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 3, 2023
Sep 9, 20229 citationsCycle 2worst F · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Oct 7, 2022
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 7, 2022
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 7, 2022
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 7, 2022
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Oct 7, 2022
  6. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Oct 7, 2022
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 7, 2022
  8. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected Oct 7, 2022
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Oct 7, 2022
Feb 15, 202219 citationsCycle 3worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 25, 2022
  2. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Mar 25, 2022
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 25, 2022
  4. F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Mar 25, 2022
  5. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Mar 25, 2022
  6. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 25, 2022
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 25, 2022
  8. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected Mar 25, 2022
  9. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Mar 25, 2022
  10. F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareD · isolatedCorrected Mar 25, 2022
  11. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Mar 25, 2022
  12. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 25, 2022
  13. F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Mar 25, 2022
  14. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Mar 25, 2022
  15. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 25, 2022
  16. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 11, 2022
  17. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Mar 25, 2022
  18. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Mar 25, 2022
  19. F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.EnvironmentalD · isolatedCorrected Mar 25, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.93hrsAbove only 21% of peers−0.54 vs MO avg
  • Registered nursesRN hours only0.09hrsAbove only 1% of peers−0.37 vs MO avg
  • Licensed practical nursesLPN hours0.77hrs
  • Nurse aidesCNA hours2.07hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.62hrs
  • Missouri average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better84%Above only 4% of peersMO avg 57%
  • RN turnoverRegistered nurses only100%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy115 certified beds · ~81 residents a day71%Above only 43% of peersMO avg 72%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $22,934In fines
  • 4Fines
  • 0Payment denials
  • $37,310MO avg in fines
Above only 31% of peersFewer fines than 31% of rated homes in Missouri

Actions on record

  1. Sep 25, 2023Civil money penalty$3,882
  2. Sep 5, 2023Civil money penalty$9,527
  3. Jul 31, 2023Civil money penalty$6,351
  4. May 30, 2023Civil money penalty$3,174

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Vertical Health Services18 facilities in the chain1.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Indirect owners (5%+)
  • Kft Irrevocable Trust
Operational or managerial control
  • Forvis Mazars LLP
  • Gwendolyn Aleem
  • Anita Crocker
  • Erika Farmer
  • Levi Lazar
  • Elizabeth Maylack
  • Emmah Mburu
  • Mona Phifer
  • +4 more
5% Or Greater Security Interest
  • Gs Capital Funding LLC

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 265719 · 5303 BERMUDA DRIVE, SAINT LOUIS, MO, 63121.
  • Percentiles compare this facility with every rated nursing home in Missouri and St. Louis County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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