Stonebridge Desoto
1550 Villas Drive, De Soto, MO 63020 · For profit - Limited Liability company · 56 certified beds · (636) 586-6559 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $6,368 in federal fines (most recent 2025-07-24)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (68%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 4 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 30.6% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 13.3% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 37.5% | 18.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.2% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 39.7% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.6% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.9% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.9% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.4% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 53.3% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.2% | 26.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.6% | 13.7% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
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.
39.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.0% 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 20 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.4%CMS range 26.0–58.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 8.5–17.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 60.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 43.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 56 beds and averages 51.3 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 is at or above 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 3.48 hrs/resident/day on weekends vs 4.02 on weekdays — 13% thinner on weekends. RN hours go from 0.70 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% is well above the national median of 45%.
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
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.
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) out of three sampled residents when staff failed to place a fall mat next to the resident's bed as directed by the care plan. The resident fell out of bed onto the floor resulting in injury. The facility census was 52. The administration was notified on 07/24/25 of the Past Non-Compliance which occurred on 07/18/25. On 07/18/25, upon notification, the facility administration started an investigation and notified the Department of Health and Senior Services of the fall which resulted in a fracture. The non-compliance was corrected on 07/18/25, as the facility in-serviced all staff on the facility's policy and procedures on Falls and Fall Risk, Managing, High Fall Risk Patient Interventions, and on the Abuse and Neglect Policy. Review of the facility policy titled, Falls and Fall Risk, Managing, revised on December 2019, showed:The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation 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.
- Potential for harm · Dcited before2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #32) out of one sampled resident. The facility's census was 46. Review of the facility's policy titled, CPAP/BiPAP Support, dated March 2015, showed: - Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the machine. Review of Resident #32's medical record showed: - admission date of 12/06/22; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems), obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), diastolic heart failure (a condition where the heart muscle becomes stiff…
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.
- Potential for harm · Dcited before2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 46. Review of the facility's policy titled, Sanitization, dated October 2008, showed: - The food service area shall be maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, and cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair; - If a sink is used for washing utensils, cooking equipment, or dishes, and also used to wash produce or thaw food, it will be cleaned between uses with an approved cleaning and sanitizing agent; - High-Temperature…
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.
- Potential for harm · Dcited before2025-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, facility staff failed to maintain appropriate infection control practices by not following enhanced barrier precautions (EBP) for one resident (Resident #20) out of three sampled residents and by not performing proper hand hygiene and glove changing techniques during incontinent care, transfer, and wound care for three residents (Resident #20, #22 and #23) out of 16 sampled residents. The facility's census was 46. Review of the facility's policy titled Enhanced Barrier Precautions, last updated 04/04/24, showed: - All staff receive training on enhanced barrier precautions upon hire and at least annually and expected to comply with all designated precautions; - All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; - The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education; - High-contact resident 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.
- Potential for harm · Ecited before2024-02-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 46. Review of the facility's Food Receiving and Storage policy, revised July 2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 1. Observation on 02/06/24 at 10:46 A.M. of the reach-in cooler showed: - One large container of Ott's Famous dressing with no opened date and no expiration date; - One large container of ranch dressing, labeled as Italian dressing, with no opened date and no expiration date; - One large container of maraschino cherries with no opened date. 2. Observation on 02/06/24 at 10:50 A.M. of a shipment of hamburger buns showed: - A large box containing individual packages of hamburger buns with a received date of 02/05/24 and a baked on date 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.
- Potential for harm · D2024-02-09 · tag F0623 — isolatedProvide 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 — the official record, unedited, 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 the resident's representative in writing of a facility-initiated transfer when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. 1. Review of Resident #44's medical record showed: - Resident transferred to the hospital for medical evaluation on 01/31/24 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 02/09/24 at 12:15 P.M., the Administrator said she would expect the resident and/or the resident's representative to receive a transfer notification in writing when a resident is transferred to the hospital. The facility did not provide a policy regarding transfers.
- Potential for harm · D2024-02-09 · tag F0625 — isolatedNotify 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 interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the facility's bed hold policy when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. Review of the facility's policy, Bed Hold Notice Prior to Transfer, revised October 2017, showed: - In the event of a resident transfer to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding the bed hold; - The notice will be provided prior to leave, if possible. In the event the notice is not provided prior to leave due to unforeseen circumstances, the notice will be provided within the requirements for such notice; - Attempts at delivery of the bed hold notice will be documented; - The following information will be given to the resident and/or resident's representative: the duration of the state bed hold, if any, during…
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.
- Potential for harm · D2024-02-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 document an accurate Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessment for two residents (Resident #11 and Resident #26) out of 12 sampled residents. The facility census was 46. Review of the facility's Certifying Accuracy of the Resident Assessment Policy showed: - All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment; - Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action and such incident must be promptly reported to the Administrator. 1. Review of Resident #11's medical record showed: - admission date of 09/07/2022; - Diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), visual loss-both eyes, and dysphagia (difficulty…
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.
- Potential for harm · Dcited before2024-02-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Life Enrichment Policy Program Policy, dated October 2017, showed: - Each resident's interests and needs will be assessed on a routine basis. Included in this assessment will be Minimum Data Set (MDS - a mandatory assessment completed by the facility) and Care Plan; - Activities will be designed with the intent to enhance the resident's sense of well being; promote or enhance emotional health; promote self esteem, dignity, pleasure, comfort, education, creativity, success and independence; - Space and equipment necessary are provided to ensure the resident's care plan is followed; - Life Enrichment Assessments, Participation reviews, and Life Enrichment Care plans will be completed on admission, quarterly, at the time a resident experiences significant change, and if the Life Enrichment Director notes an inherent trend…
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.
- Potential for harm · D2024-02-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 update and revise a comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Comprehensive Care Plans Policy, dated September 2022, showed: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; - The care planning process will include an assessment of the resident's strengths and needs; - The comprehensive care plan will be reviewed and revised by the interdisciplinary team (a group of professionals from different disciplines that know the resident's needs) after each comprehensive (no more than 366 days from prior comprehensive assessment) and…
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.
- Potential for harm · D2024-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 resident care for activities of daily living (ADLs) when residents did not receive scheduled showers and preferences were not acknowledged for three residents (Resident #10, #30, and #46) out of 12 sampled residents. The facility census was 46. The facility's policy did not address shower frequency. 1. Review of Resident #10's medical record showed: - admission date of 04/25/23; - Diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, causing significant impairment in daily life), mild cognitive impairment, lack of coordination, unsteadiness on feet, weakness, high blood pressure, and heart failure. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/18/24, showed: - Moderately impaired cognition; - Moderate assistance for upper body dressing and personal hygiene; - Dependent…
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.
Show the remaining 14 citations
- Potential for harm · D2024-02-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #3 and #11) out of two sampled residents. The facility census was 46. Review of the facility's Restorative Nursing Services Policy Statement, dated July 2017, showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative goals and objectives are individualized and resident centered and are outlined in the resident's plan of care; - The resident or representative will be included in determining goals and the plan of care. 1. Review of Resident #3's medical record showed: - admission date of 05/11/22; - Diagnoses of contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to shorten and become very stiff) of unspecified joint,…
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.
- Potential for harm · Dcited before2024-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to obtain orders for continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) settings and tubing changes for one resident (Resident #31) out of one sampled resident with a CPAP and failed to obtain a physician's order prior to oxygen use and orders for nasal cannula (a small, flexible tube that contains two open prongs that sits in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for one resident (Resident #100) out of one sampled resident with oxygen. The facility census was 46. Review of the facility's policy, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - Policy did not address CPAP use. 1. Review of Resident #31's medical record showed: - An…
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.
- Potential for harm · Dcited before2024-02-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 46. Review of the facility's policy titled, Storage of Medications, dated April 2007, showed: - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Review of the manufacturer's recommendations for Tubersol (a solution used for a tuberculosis (TB), a contagious lung disease test) showed: - The medication to be discarded 30 days after opening; - Store medication at 35 to 46 degrees Fahrenheit.…
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.
- Potential for harm · D2024-02-09 · tag F0868 — isolatedHave 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 and record review, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility census was 46. Review of the facility's QAPI Plan, dated September 2022, showed: - The QAPI committee will meet at least quarterly and as needed; - The committee will be made up of, at a minimum, the Director of Nursing (DON), the Medical Director or designee, Administrator, and at least three other members of the facility staff. 1. Review of QAPI Meeting information, dated 01/04/24 and provided by the Administrator, showed no record of Director of Nursing (DON) or Infection Preventionist (IP) attending meeting. 2. Review of QAPI Meeting information, dated 12/27/23 and provided by the Administrator, showed no record of the Medical Director or IP attending meeting. 3. Review of QAPI Meeting information, dated 10/11/23 and provided by the Administrator, showed no record of the IP attending meeting. 4. Review of QAPI Meeting information, dated 09/13/23 and provided by the Administrator, showed no record 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.
- Potential for harm · Dcited before2024-02-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the prevention of communicable disease in regards to Tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening/testing for three residents (Resident #32, #44, and #46) out of five sampled residents and failed to use proper hand hygiene during care of four residents (Resident #16, #17, #32, and #100) out of 12 sampled residents and two residents outside the sample (Resident #4 and #24). The census was 46. 1. Review of the facility's Screening Residents for TB policy, revised December 2016, showed: - The facility shall screen all residents for tuberculosis infection and disease; - The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of TB and will check results of recent tuberculin skin tests, blood assay, or chest x-rays; - Any resident without documented negative Tuberculosis Skin Test (TST), Blood assay for Mycobacterium tuberculosis…
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.
- Potential for harm · D2024-02-09 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to designate a qualified individual as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 46. The facility did not provide a policy regarding required specialized training for the IP. Review of the prior certifications and employment record showed the prior Director of Nursing (DON) obtained certification on 10/24/23 and was no longer employed as of 12/27/23. During an interview on 02/06/24 at 3:24 P.M., the DON said she is the IP and started taking the certification classes in November or December of 2023. During an interview on 02/06/24 at 3:26 P.M., the Administrator said the DON is the IP, but she has not completed training, and there is not a back up IP.
- Potential for harm · D2023-09-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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's orders for one resident (Resident #1) out of three sampled residents. The facility's census was 51. Review of the facility's policy titled, Discontinued Medications, revised April 2007, showed: - A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record; - The nurse receiving the order to discontinue a medication is responsible for recording the information and notifying the dispensing pharmacy; - Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. Review of Resident #1's medical record showed: - An admission date of 08/10/23; - Diagnoses of spontaneous bacterial peritonitis (infection of ascites, abnormal collection of fluid in the abdomen), hepatic encephalopathy (loss of brain function when a damaged liver does not remove toxins), alcoholic cirrhosis of liver 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.
- Potential for harm · Ecited before2022-08-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 46. 1. Observations of the kitchen on 8/2/22 10:58 A.M., showed: - Ice machine drain pipe with an air gap set at one inch (in) near the floor drain and the pipe covered in black grime; - Ice machine drain pipe not aligned over the floor drain and water dripped on the floor; - Walk in refrigerator door drug the floor and loose at the hinges; - Walk in freezer temperature of 4 degrees Fahrenheit with some large ice formed on the refrigeration lines; - Ice formed on food boxes under the fan in the back of the freezer and on the floor; - The walk in freezer door seal damaged and loose near the top left corner of the door; - Light visible through the corner of the door when shut; - Six in of the door gasket loose at the top along the side of the freezer door; - Food stock room ceiling air vent cover coated in dust…
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.
- Potential for harm · Ecited before2022-08-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain infection control practices for four sampled residents (Residents #20, #21, #28, and #37) and three residents outside of the sample (Residents #8, #11, and #14) during medication administration when facility staff did not wash or sanitize their hands during medication administration. The facility staff also failed to follow appropriate infection control practices when staff administered a medication to a resident (Resident #11) that fell on the resident's chest and staff picked the medication up with his/her bare hand and administered it. Staff also did not wear gloves during insulin (a hormone injected just under the skin to lower blood sugar) administration. The facility's census was 46. Record review of the facility's Administering Medications policy, revised December 2012, showed: - Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review…
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.
- Potential for harm · Dcited before2022-08-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a comprehensive care plan for a specialty care area for two residents (Residents #10 and #28) out of a sample of 12 residents. The facility census was 46. Record review of the facility's Comprehensive Person-Centered Care Plan policy, dated December 2016, showed: - The comprehensive, person-centered care plan will include measurable objectives and timeframes; - Describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; - Incorporate identified problem areas; - Incorporate risk factors associated with identified problems; - Reflect the resident's expressed wishes regarding care and treatment goals; - Aid in preventing or reducing a decline in the resident's functional status and/or functional levels; - Identify problem areas and their causes, and develop interventions targeted and meaningful to the resident at the endpoint of an interdisciplinary process. Record…
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.
- Potential for harm · D2022-08-05 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 33 opportunities with eight errors made, for an error rate of 24.24%. Out of seven residents observed, this affected three sampled residents (Resident #20, #21, and #37) and one resident (Resident #11) outside the sample. The facility census was 46. Record review of the facility's Administering Medications policy, revised December 2012, showed: - Medications must be administered in accordance with the orders, including any required time frame; - Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); - The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. Record review of Resident #11's Physician Order Sheet (POS), dated August 2022, showed: - An order…
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.
- Potential for harm · Dcited before2022-08-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 46. Record review of the facility's Storage of Medication policy, dated April 2007, showed: - Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which received. Only the issuing pharmacy will be authorized to transfer medications between containers; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location under proper temperature controls. Record review of the manufacturer's recommendations for the Tubersol (a solution for a tuberculosis test) showed: - The medication to be discarded 30 days after opening. Observation on 8/4/22 at 2:15 P.M. of the medication room refrigerator showed:…
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.
- No harm found · C2025-03-13 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide access to survey results. This had the potential to affect all residents. The facility census is 46. Review of the facility's policy titled, Examination of Survey Results, dated April 2007, showed: - A copy of the most recent standard survey along with state approved plans of correction of noted deficiencies, is maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. Observations from 03/10/25 through 03/13/25 showed: - On 03/10/25 at 11:35 A.M., no survey binder was found at the nurses' station or activities room; - On 03/13/25 at 2:15 P.M., no survey binder was found at the nurses' station or activities room. During an interview on 03/13/25 at 10:10 A.M., Resident #25 said he/she was not aware the survey results could be read or where to find them. During an interview on 03/13/25 at 10:10 A.M., Resident #4 said he/she did not know where to find the survey results. During an interview on 03/13/25 at 10:10 A.M., Resident #35…
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.
- No harm found · C2024-02-09 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide resident rights information on how to formally file a complaint to the Department of Health and Senior Services (DHSS) about the care they were receiving. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. Review of the facility's policy titled, Resident Right Policy, dated 2017, showed: - Information about resident rights and responsibilities will be given to the resident both orally and in writing; - A posting of names, addresses, and phone numbers of all pertinent state client advocacy groups will be available in the facility. During a group interview on 02/08/24 at 10:00 A.M., five residents (Resident #15, #20, #25, #29, and #101) collectively said they had not been given information or informed on how to make a formal complaint to DHSS about the care they received. Observation of the facility on 02/08/24 at 10:25 A.M. showed no posting containing the DHSS contact information. During an interview on 02/09/24 at 5:17 P.M., Nursing…
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.
“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.
- 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.
Fines & penalties
$6,368 in federal fines across 1 penalty.
- $6,368 — penalty dated 2025-07-24
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 STONEBRIDGE SENIOR LIVING — 12 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 4 of 5 | 3.5 | +0.5 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 11 homes this chain runs (chain average 3.3★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIERMAN, MARK | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 11/01/2021 |
| MILLER, BETH | Individual | CORPORATE OFFICER | — | since 01/17/2023 |
| BRIDGE REHABILITATION INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2024 |
| BUSEY CORPORATION | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/10/2023 |
| ELDERCARE MANAGEMENT SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/12/2008 |
| DOERHOFF, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2021 |
| LESSOR, JENNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/16/2023 |
| LUM, LAURENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| THAYER, JEANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2021 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 01/25/2016 |
| LIERMAN FAMILY CO IV, LLC | Organization | ADP OF THE SNF | — | since 03/12/2008 |
| WIPFLI LLP | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| COOK, KELLIE | Individual | ADP OF THE SNF | — | since 07/07/2011 |
CMS files one row per role, so the 22 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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.
This home reported $804K 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
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 265772. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, 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.