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Sunterra Springs Dardenne Prairie

7275 State Highway N, Dardenne Prairie, MO 63368 · For profit - Limited Liability company · 38 certified beds · (636) 865-0200 Medicare only — no Medicaid

Call the home — (636) 865-0200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$49,722 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $49,722 in federal fines (most recent 2025-06-13)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (76%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
301 Caledonia Pkwy Ste 120 · (636) 202-6805 · Call to confirm hours
Pharmacy
7422 Town Square Ave · (636) 625-5012 · Call to confirm hours
Grocery
Aldi1.5 mi
464 Hawk Ridge Trl · (855) 955-2534 · Call to confirm hours
Park
2032 Hanley Rd · (636) 561-1718 · Typically dawn to dusk
Place of worship
2199 Post Rd · (636) 625-2344

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.7%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine82.8%63.5%79.4%typical
Short-stay residents rehospitalized after admission27.8%26.0%22.6%worse
Short-stay residents with an outpatient ER visit7.8%13.7%12.0%better

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

59.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 527 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
74.0%U.S. median 56.6%
Met the expected recovery
0.90U.S. median 0.31
Therapy hours / resident / day
0.45hours / resident / day
Physical therapy
0.40hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 74.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 231 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.90 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.4%CMS range 54.8–63.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 9.3–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge74.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge81.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge69.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 3.8–7.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.10
RN hours/ resident / day
1.16
LPN hours/ resident / day
2.20
Aide hours/ resident / day
4.46
Total nurse hours/ resident / day
0.86
RN hoursweekends
76.1%
Total nursing turnover
88.9%
RN turnover

How full it usually is: this home is certified for 38 beds and averages 32.2 residents a day — about 85% occupied, or roughly 6 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.92 hrs/resident/day on weekends vs 4.67 on weekdays — 16% thinner on weekends. RN hours go from 1.19 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-01-15)
15
at the previous standard inspection (2023-11-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of seven sampled residents. While assisting the resident to transfer from the toilet to his/her new motorized chair, staff ran the motorized chair over the resident's left foot. The resident sustained a fractured toe. The facility census was 66. Review of the facility policy for Accidents and Supervision dated 07/2024 showed the following:-The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devises to prevent accidents. This includes identifying hazards(s) and risk(s); evaluating and analyzing hazards(s) and risk(s); implementing interventions to reduce hazards(s) and risk(s); monitoring for effectiveness and modifying interventions when necessary;-The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents;-All staff are…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-03-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete weekly skin assessments per facility policy for two residents, (Resident #1 and #2), of five sampled residents. Resident #1 admitted to the facility with no pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Staff failed to identify any issue with the resident's skin before the resident presented with a Stage III pressure ulcer on the resident's buttocks on 1/19/25 (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Resident #2 was at risk for pressure ulcers and admitted to the facility without pressure ulcers. The resident was dependent on staff for cares, was not consistent in keeping pressure off his\her heels, and would…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-09-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of four sampled residents, who was dependent upon staff for transfers and at risk for falls. The facility failed to ensure staff followed facility policy for using a sit to stand lift. Certified Nurse Aide (CNA) A transferred Resident #1 using the sit to stand lift without assistance of an additional staff to transfer the resident. The resident sustained significant pain and bruising from the improper transfer. The facility census was 36. The administrator was notified on 9/30/24 at 3:00 P.M , of the Past Non-Compliance which occurred on 9/24/24. On 9/24/24, the administrator became aware of the injury to Resident #1 which resulted in a staff member failing to follow the facility policy on a sit to stand transfer when the staff member did not use two staff to transfer the resident. The facility began an investigation and determined that the staff did not follow the facility policy for a sit to stand…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation of ongoing assessments of a surgical wound as directed in facility policy for one resident (Resident #1), in a review of eight sampled residents, when the resident's wound deteriorated. The facility failed to notify the surgeon when the wound had an increase in bleeding for four days which caused a delay in the resident being sent to the emergency department following a miscommunication and a missed appointment with the surgeon. The facility census was 32.Review of the facility's policy, Wound Treatment Management, last revised 04/2025, showed the following:-It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-Treatment decisions will be based on etiology of the wound, characteristics of the wound and location of the wound;-The facility will follow specific physician orders for providing wound care and are able to provide standard of care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-15 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed follow discharge process per facility policy. Staff failed to provide a copy of bed hold policy and written notice of transfer to the resident and/or the resident's representative when four residents (Residents #42, #34, #9 and #47), in a review of 15 sampled residents, were transferred/discharged from the facility. The facility census was 32. Review of the facility's policy for transfer/discharge notices, last revised April 2025, showed the following:-The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and way they can understand. The notice will include all the following at the time it is provided: -The specific reason and basis for transfer or discharge; -The effective date of transfer or discharge; -The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged ;-Emergency…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-15 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #34), in a review of 14 residents and two additional residents (Resident # 100 and # 101) were free from significant medication errors. Staff failed to prime (remove the air) insulin (injectable medication to treat diabetes (inability to control the amount of sugar in the blood)) pens prior to administration of the physician ordered dose, as the facility policy and manufacturer's instructions directed, resulting in administration of less than the ordered dose of insulin. The facility census was 32. Review of the facility policy, Insulin Pen, revised 04/25, showed the following:-It is the policy of this facility to use insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;-Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Review of the Lispro Kwik Pen (prefilled pen of fast acting insulin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow current infection control standards for five residents (Resident #4, #40, #41, #56 and #57), in a review of 15 sampled residents, when staff failed to perform proper hand hygiene, change gloves, properly handle contaminated linens and follow enhanced barrier precautions (EBP) by wearing personal protective equipment (PPE) to prevent infection while providing personal care. The facility census was 32. Review of the facility policy, Hand Hygiene, revised 04/2025, showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility;-Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR);-Staff will perform hand hygiene when indicated, using proper technique…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow current infection control standards for four residents (Resident #1, #3, #7 and #10), in a review of ten sampled residents when staff failed to perform proper hand hygiene and change gloves to prevent infection during personal care for Resident #1, #3, #7 and #10, and failed to properly handle soiled linens during personal care for Resident #10. The facility census was 29.Review of the facility policy for Hand Hygiene with a revision date of 4/2025 showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to tother personnel, residents and visitors. This applies to all staff working in all locations within the facility;-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hands hygiene…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed physician orders for two residents (Resident #4 and #5) of ten sampled residents. Staff failed to follow physician orders for dressing changes to intravenous (IV) sites and wounds and failed to follow physician orders to secure an indwelling catheter. The facility census was 29.The facility provided no policy for following physician orders upon request.Review of the facility policy Wound Treatment Management with a revision date of 4/2025 showed the following:-To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders;-The facility will follow specific physician orders for providing wound care.Review of the facility policy Skin Assessment with a revision date of 4/2025 showed the following:-It is our policy to perform a full body skin assessment as part of our systematic approach to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to secure indwelling catheter drainage tubing and bags for two residents (Resident 4, and #5), in a review of ten residents with indwelling catheters. These failures increased the residents' risk for urinary tract infections. The facility census was 29. Review of the facility policy for Catheter Care with a revision date of 4/2025 showed the following:-It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;-Catheter care will be performed every shift and as needed by nursing personnel;-Privacy bags will be available and catheter drainage bags will be covered at all times while in use;-Catheter drainage bags will be positioned below bladder level, clear from floor, and will not be level with the resident while the resident is in bed;-Ensure the drainage bag is located below the level of the bladder to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one resident's (Resident #1) physician, in a review of three sampled residents, that ordered medications were not available for administration. The census was 36. Review of the facility policy, Notification of Changes, last revised 4/2025 showed the following: -The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; Circumstances requiring notification include those that potentially may require physician intervention including circumstances that require a need to alter treatment. 1. Review of Resident #1's facility medical record showed the resident admitted to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders for one resident (Resident #1), in a review of three sampled residents, when staff did not administer medications or complete assessments as ordered. Further review showed the medications not administered were available through the facility Pyxis (emergency medication supply available for the facility to pull medication from and use for resident administration) system and as stock medications. The census was 36. Review of the facility policy, Medication Administration, last revised 7/2024, showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice; Policy Explanation and Compliance Guidelines: 9. Review Medication Administration Record (MAR) to identify medication to be administered; 10. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and/or responsible parties when two residents (Residents #1 and Resident #2), in a review of six sampled residents, had a change in condition. The facility census was 34. Review of the facility policy for Notification of Changes dated 7/2024 showed the following: -The purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification; -Circumstances requiring notification include significant change in the residents physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and transfer or discharge of a resident from the facility; -The facility must still contact the residents physician and notify the resident's representative, if known; -When a resident is mentally competent, such a designated family should be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-01-31 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to ES4312 Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; and using speech, language or other functional communication systems; -The resident who is unable to carry out activities of daily living will receive the necessary services to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-31 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to ES4312 Based on interview and record review, the facility failed to follow professional standards of practice for two residents (Residents #11 and #12), in a review of 21 sampled residents. The facility failed to document the administration of narcotics. The facility census was 29. Review of facility policy for Medication Administration dated 6/2023 showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Administer medication as ordered; -Sign the MAR after administration; -If the medication is a controlled substance, sign the narcotic bock. Review of the facility policy for controlled Substance Administration and Accountability policy dated 6/2023 showed the following: -It is the policy of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to ES4312 Based on observation, interview, and record review, the facility failed to provide timely assistance for one dependent resident (Resident #10), in a review of 12 sampled residents when the resident was incontinent. Staff failed to provide incontinence care when staff found the resident incontinent of feces. The resident lay soiled for approximately two hours and reported staff would turn off her call light and not assist him/her. The resident reported he/she had to eat breakfast while wearing a soiled brief. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for bathing, dressing, grooming and oral care, transfer and ambulation, toileting and eating to include meals and snacks; -The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility policy review, the facility failed to ensure clean pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 38 of 38 residents in the facility who received dietary services at the time of the survey. The census was 38. Findings include: Review of the facility policy ''Dishwashing Machine Use,'' dated March 2010, revealed, ''Policy Statement: Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: . i. Use overhead spray to remove loose food particles. J. After running items through the entire cycle, allow to air-dry.'' Review of the facility policy ''Manual Ware Washing - 3 Compartment Sink,'' dated June 2023, revealed, ''Policy: To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policies, the facility failed to ensure that staff and visitors were wearing the appropriate personal protective equipment (PPE) for one resident of two residents (Resident (R) 90) on isolation precautions. The facility failed to ensure the water management program was consistently maintained. The census was 38. Findings include: 1. Review of the facility policy titled ''Personal Protective Equipment'' with revision date of [DATE] read in part, ''. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely . PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status .'' Observation on [DATE] at 11:30AM revealed R90 in a room with signage that read airborne precautions. The signage…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-30 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure staff provided three residents (Resident #8, #9 and #10), in a review of 12 sampled residents, showers per their preferences. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care; transfer and ambulation; toileting; eating to include meals and snacks; and using speech, language or other functional communication systems; -The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-30 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy the facility failed to ensure that baseline care plans were developed and/or presented to the resident and/or the responsible party within 48 hours of admission for 13 residents (Resident (R) 1, R83, R90, R14, R15, R20, R30, R3, R4, R18, R29, R134, and R135) reviewed for baseline care plans. The census was 38. Findings include: Review of the facility policy titled ''Base Line Care Plans'' with a revision date of [DATE] read in part ''.To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The resident and their representative will be provided a summary of the baseline care plan .'' 1. Review of R1's undated ''Face Sheet,'' located in the resident's electronic medical records (EMR) section titled ''Face Sheet,'' revealed the resident was admitted on [DATE] with diagnoses that included displaced fracture of right lower leg,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of facility policy, the facility failed to ensure that two of two medication carts and one of two treatment were locked and secured on two of two resident halls. This failure creates a risk of medications being misappropriated or tampered with. The census was 38. Findings include: Review of the facility's policy titled ''Medication Storage'' with a revision date of June 2023 read, ''All drugs and biologicals will be stored in in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During a medication pass the medication cart must be under direct observation of the person administering medications or locked in the medication storage area/cart.'' 1. Observation on 11/29/23 at 8:39 AM revealed the 100 Hall medication cart parked across from the Physical Therapy department and nurses' station unlocked. There were no medications on top of the cart. Non-nursing facility staff members (physical therapy and dietary) were nearby. At 8:43AM, the Assistant Director of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility policy the facility failed to maintain a clean environment for one of two residents (Resident (R )90) in contact isolation from a sampled 15 residents. The census was 38. Findings include: Review of the facility policy titled ''Handling Soiled Lined'' with a revision date June 2023 stated ''. Used or soiled linen shall be collected at the bedside (or point such as dining room) and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed and securely placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.'' Observation on 11/29/23 at 9:10 AM of R90's room revealed R90 in droplet/contact isolation for positive COVID diagnosis. In the resident's bathroom one large yellow plastic bag filled with dirty linen and a large blue bag also filled with dirty stained linen was sitting on the floor next to the shower. There was a strong urine and fecal odor in the bathroom. The trash can by the resident's room door was overflowing with used personal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or resident's responsible party and the Ombudsman of a transfer or discharge in writing for two of two residents (Resident (R) 18 and R30) reviewed for hospitalization. The census was 38. Review of the facility policy Notification of Changes dated 06/2023 (sic), revealed, the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. If the resident is competent the facility must still contact the resident's physician and notify the resident's representative if known. If the resident is incapable of making decisions the representative would make any…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed ensure two of two residents (Resident (R) 18, and R30) reviewed for hospital transfers were given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility. The census was 38. Findings include: Review of the facility policy ''Bed Hold Notice Upon Transfer,'' dated June 2023, revealed, at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of practice for two residents (Residents #11 and #12), in a review of 21 sampled residents. The facility failed to document the administration of narcotics. The facility census was 29. Review of facility policy for Medication Administration dated 6/2023 showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Administer medication as ordered; -Sign the MAR after administration; -If the medication is a controlled substance, sign the narcotic bock. Review of the facility policy for controlled Substance Administration and Accountability policy dated 6/2023 showed the following: -It is the policy of this facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely assistance for one dependent resident (Resident #10), in a review of 12 sampled residents when the resident was incontinent. Staff failed to provide incontinence care when staff found the resident incontinent of feces. The resident lay soiled for approximately two hours and reported staff would turn off her call light and not assist him/her. The resident reported he/she had to eat breakfast while wearing a soiled brief. The facility census was 29. Review of the facility policy for Activities of Daily Living (ADLs) dated 6/2023 showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for bathing, dressing, grooming and oral care, transfer and ambulation, toileting and eating to include meals and snacks; -The resident who is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of facility the facility failed to properly secure foley catheters and position the urinary drainage bags for two residents from four residents (Resident (R) 3 and R90) with indwelling catheters. These failures increased the risk for urinary tract infections in the residents. The census was 38. Findings include: Review of facility policy titled ''Indwelling Catheter Use and Removal'' with a revision date of June 2023 read, ''Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to tears or dislodgement of the catheter and securement of the catheter to the facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder.'' 1. Review of R90's undated ''Face Sheet'' located in the resident's electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage II, benign prostatic hyperplasia with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for Resident (R) 92 were made from 25 opportunities during medication administration. The medication error rate was 8.0 percent. The census was 38. Findings include: Review of the facility policy titled ''Medication Administration'' with a revision date June 2023 read in part, ''Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state. As ordered by the physician and in accordance with professional standards of practice .'' Review of the facility policy titled, ''Medication Cross Match'' with a revision date of June 2023, read in part, ''. The nurse assigned to the medication cart nightly will perform a medication cross match. The one-day supply will be delivered Monday through Friday. There will be a three-day supply delivered on Friday for Saturday,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that one resident out of 15 sampled residents (Resident (R) 92) received the anticoagulant medication according to the physician's orders. This failure to provide the anticoagulant had the potential to contribute to the development of thrombosis (blood clots). The census was 38. Findings include: Review of the facility policy titled ''Medication Cross Match'' with a revision date of June 2023 read in part ''. The nurse assigned to the medication cart nightly will perform a medication cross match. The one-day supply will be delivered Monday through Friday. There will be a three-day supply delivered on Friday for Saturday, Sunday, and Monday. The nurse performing the medication cross match will review and compare the Medication Administration Record (MAR) with the medications available in the cart and medication room. If the medication is not available, the nurse will notify the on call pharmacist.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed to ensure garbage was properly disposed of and contained for one of one facility dumpsters. The census was 38. Findings include: Review of the facility's policy titled, ''Disposal of Garbage and Refuse,'' dated 06/2023 (sic), revealed, ''Policy: The facility shall properly dispose of kitchen garbage and refuse. Policy Explanation and Compliance Guidelines: . 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8. Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster . 10. Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings for two of four quarters reviewed. The census was 38. Findings include: Review of the facility document titled, Rocky Mountain Care SNF [Skilled Nursing Facility] - Policy and Procedure Manual QAPI [Quality Assurance and Performance Improvement] Process, dated 09/21/22, revealed, Policy: The facility has established and utilizes a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. Policy Explanation and Compliance Guidelines: 1. Facility has in operation a Quality Assessment and Assurance (QAA) Committee that is responsible for coordinating and evaluating activities under the facilities QAPI program . Further review of the facility policy revealed it failed to identify the required members who must attend the quarterly meetings. An attempt was made to review the sign-in sheets…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$49,722 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $10,546 — penalty dated 2025-06-13
  • $39,176 — penalty dated 2025-03-19
  • Medicare payment denial — starting 2025-04-25 for 5 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SUNTERRA SPRINGS — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.8-1.8 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 4 of 54.8-0.8 vs chain
The other 3 homes this chain runs (chain average 3.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
RMC ENTERPRISES LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
BALL VENTURES LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2025
BV OPERATIONS LLC.OrganizationINDIRECT OWNERSHIP INTERESTsince 04/01/2025
BV PAC HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
DLB LEGACY LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
RMCE OPERATIONS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/15/2026
BALL, ALLENIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2025
BALL, CONNIEIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2025
BANGERTE, NATHANIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODYsince 03/28/2025
BANGERTER, DEEIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2025
BANGERTER, EDWARDIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/13/2026
BANGERTER, JOHNATHANIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODYsince 04/01/2025
SHRADER, RICHARDIndividualINDIRECT OWNERSHIP INTERESTsince 03/28/2025
DARBY, MEGANIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2025
GATHERUM, JASONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
HANSEN, KENTIndividualMANAGING CONTROL - GOVERNING BODYsince 08/12/2025
NEVES, COURTNEYIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2025
OWENS, JONIndividualMANAGING CONTROL - GOVERNING BODYsince 08/12/2025
SNOWBALL, KELLYIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2025
MEYERSON, LEWISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/18/2018
SLABY, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/03/2025
STEVENS, GARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
ROCKY MOUNTAIN CARE LLCOrganizationADP OF THE SNFsince 12/03/2025

CMS files one row per role, so the 33 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.4M
Net patient revenuemost recent cost report
-14.7%
Operating marginrevenue minus expenses
$867K
Related-party expense14% of expenses

This home reported $867K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$698per resident / day
operating cost
$21,209per month
≈ monthly operating cost
$608per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Missouri Medicaid page for homes that do.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265881. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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