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Stonebridge Villa Marie

1030 Edmonds Street, Jefferson City, MO 65109 · For profit - Corporation · 120 certified beds · (573) 635-3381 Medicare & Medicaid certified

Call the home — (573) 635-3381 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Jan 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (74%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Urgent care / clinic
1233 Jefferson St · (573) 634-7000 · Call to confirm hours
Pharmacy
1125 Madison Street, Floor 2 · (573) 632-5295 · Call to confirm hours
Grocery
1418 Missouri Blvd · (573) 893-2930 · Call to confirm hours
Park
1200 Washington Park Dr · (573) 634-6482 · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 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 2 to 1 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 rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased39.4%18.1%15.4%worse
Long-stay residents who lose too much weight10.2%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.1%1.1%0.9%worse
Long-stay residents with a urinary tract infection0.8%2.3%2.0%better
Long-stay residents with depressive symptoms14.6%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury9.4%4.1%3.3%worse
Long-stay residents whose ability to walk worsened31.4%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.3%25.6%18.9%better
Long-stay residents given the seasonal flu vaccine82.9%90.9%95.3%worse
Long-stay residents with pressure ulcers6.5%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control21.1%17.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table35.9%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.5%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine33.3%63.5%79.4%worse
Short-stay residents rehospitalized after admission33.8%26.0%22.6%worse
Short-stay residents with an outpatient ER visit6.3%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.942.111.67worse
Long-stay outpatient ER visits per 1,000 resident days1.332.331.80better

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.

41.3% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.3%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.09U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF41.3%CMS range 27.8–57.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 7.2–17.710.7%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 discharge50.0%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 discharge50.0%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 discharge55.0%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 identified30.0%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 settingnot 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 dischargenot 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 stay3.3%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 worsened13.3%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 hospitalizationnot 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 SNFs0.931.02Oct 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

0.39
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.15
Total nurse hours/ resident / day
0.34
RN hoursweekends
74.3%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 64.7 residents a day — about 54% occupied, or roughly 55 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 2.79 hrs/resident/day on weekends vs 3.30 on weekdays — 15% thinner on weekends. RN hours go from 0.41 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 74% 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

8
deficiencies at the latest standard inspection (2026-03-13)
7
at the previous standard inspection (2024-08-09)

Deficiencies are more than at the previous inspection — worsening. 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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Ecited before2026-03-13 · 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 observation, interview, and record review, facility staff failed to remove and discard discontinued medication and improperly labeled medication from two of two medication carts and one of two medication rooms. The facility census was 62.1. Review of the facility's policy titled Labeling of Medication Containers, revised 04/07, showed medications shall contain the expiration date when applicable.Review of the facility's policy titled Storage of Medications, revised 04/07, showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be destroyed.Review of the facility's policy titled Discarding and Destroying Medications, revised 10/16, showed medications will be disposed of in accordance with federal, state, and local regulations.2. Observation on 03/12/26 at 9:46 A.M., showed the rehabilitation medication cart contained:-One bottle of Oyster Shell Calcium 500 milligram (mg) with Vitamin D with expiration date of 11/25;-One Novolog Insulin (a short-acting insulin) pen with an open date of 02/11/26, and an expiration…

    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 before2026-03-13 · 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, facility staff failed to use enhanced barrier precautions (EBP, an infection control practice that requires staff to wear personal protective equipment (PPE, protective equipment such as gowns, gloves, goggles, and masks) to prevent or minimize exposure to hazards) for four residents (Resident #1, #5, #20, and #28) of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Enhanced Barrier Precautions, dated 04/04/24, showed it is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refers to the use of gowns and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated…

    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 · D2026-03-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 observation, interview, and record review, facility staff failed to develop a comprehensive care plan to reflect the care needs of two residents (Resident #1 and #28) out of 17 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised 10/17, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her representative develops and implements a comprehensive, person-centered care plan for each resident; -Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change; -The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired…

    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 before2026-03-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, facility staff failed to update care plans to address the care needs of four residents (Residents #6, #7, #20, and #43) out of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2017, showed a comprehensive, person-centered care plan will describe services that would otherwise be provided but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; and will aid in preventing or reducing decline in the resident's functional status and/or functional levels. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcomes are not met; and at least quarterly in conjunction with the required…

    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 before2026-03-13 · 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

    Based on observation, interview, and record review, facility staff failed to document falls and neurological assessment for one resident (Resident #1) of two sampled residents. The facility census was 62.1. Review of the facility's policy titled Falls, revised 04/22 showed staff will evaluate and document falls that occur including an observation of the event identifying them as witnessed or unwitnessed. The nurse will assess and report the resident's neurological status; Review of the facility's policy titled Neurological Assessment, revised 10/2010, showed a neurological assessment is to be completed upon physician's order, after an unwitnessed fall, after a fall with suspected head injury, and when indicated by resident condition. Perform neurological checks with frequency as ordered per fall protocol. If the resident refused the procedure document the refusal.Review of the facility's form titled Post Fall 72 Hour Monitoring Report, dated 07/08, showed this assessment should be completed at the following intervals for a fall that is unwitnessed or in which the head is struck…

    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 · D2026-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, facility staff failed to obtain orders for a Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilator) for one resident (Resident #2) of one sampled. The facility census was 62.1. Review of the facility's policy titled Oxygen Safety, revised 01/18, showed staff, residents and families will be educated on oxygen safety precautions in accordance with their roles and responsibility. Review of the facility's policy titled BiPAP Support, revised 03/25, showed only a qualified and properly trained staff member should administer oxygen through a BiPAP mask. Review the physician's order to determine the oxygen concentration and flow, and the Positive End Expiratory Pressure (PEEP) pressure for the machine. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/17/26, showed staff assessed the resident as cognitively intact with diagnoses of respiratory failure and obstructive sleep apnea (periods of breathlessness during sleep). Review of the resident's care plan,…

    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 · D2026-03-13 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 obtain physician's orders for the use of side rails for two residents (Resident #2 and #23) of three sampled residents. The facility census was 62. 1. Review of the facility's policy titled Proper Use of Side Rails, revised 09/22, showed the facility will obtain a physician's order for the use of the specific side rails and medical diagnosis, condition, symptoms, or functional reason for the use of side rails. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, revised 02/21/26, showed staff documented a physician's order will be current for side rails to be used. Review of the resident's Physician Order Sheet (POS), dated 03/10/26, did not contain orders for side rail use. Observation on 03/11/26 at 10:15 A.M., showed the resident in bed with both upper side rails in the upright position. Observation on 03/12/26…

    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 · Ecited before2025-07-17 · 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, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during perineal care for two residents (Resident #1, and #2) of two sampled residents, and failed to properly dispose of contaminated linens from one resident's (Resident #3's) room. Facility staff failed to implement the enhanced barrier precautions (EBP) (an infection control intervention) policy when they did not properly alert staff of residents who required EBP and place appropriate personal protective equipment (PPE) in proximity for one resident (Resident #1) of one sampled resident that required EBP during perineal care and wound care. The facility census was 68. 1. Review of the facility's Infection Prevention and Control Manual-Standard Precautions policy, dated 2017, showed staff are directed as follows:-Hand hygiene continues to be the primary means…

    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 before2025-07-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, facility staff failed to review and revise the plan of care with changes in the resident's needs for three residents (Resident #4, #5, and #6) out of three sampled residents. The facility census was 68.1. Review of the facility's Comprehensive Care Planning policy, dated 02/25, showed staff are directed as followed:-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 [NAME] and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; -The care plan process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care; -The policy did not contain direction for staff in regard to revision after a change in condition or…

    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 · D2025-01-22 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, facility staff failed to thoroughly investigate an allegation of sexual assault for one resident (Resident #1) out of one sampled resident. The facility census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; -The Abuse Coordinator in the facility is the Administrator, or facility appointed designee when the Administrator is absent. -Report allegations or suspected abuse, neglect, or exploitation immediately to the Administrator, Law Enforcement, and State Survey and Certification Agency through established procedures. --For investigation of alleged abuse, neglect and exploitation: When suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur, an investigation is immediately warranted. Components of an investigation may include: -Interview the involved…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-01-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, facility staff failed to contact local law enforcement, and failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe for one resident (Resident #1) out of one sampled resident with an allegation of sexual abuse. The facility's census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or resulting in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 66. 1. Review of the facility's Food Services Manager policy, dated December 2008, showed the daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 07/28/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-09 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 66. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed that menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. 2. Review of the facility menus, dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on regular and dental/mechanical soft diet with a two inch by three inch cream cheese brownie at the lunch meal. Observation on 08/08/24 at 12:16 P.M., showed dietary staff with the noon meal,did not prepare or serve the cream cheese brownies as directed by the menus to residents who received regular and dental/mechanical soft diets. During an interview on 08/08/24 at 1:22 P.M., the dietary manager (DM) said staff should serve food in accordance with planned menus and he/she is responsible to ensure the full meal is served. The DM said he/she did not know why staff did not make the brownies…

    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 before2024-08-09 · 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, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to thaw frozen foods in a manner to prevent the growth of food-borne pathogens and cross-contamination with ready-to-eat food items. Facility staff failed to allow sanitized dishes to air dry before being stacked in storage to prevent the growth of food-borne pathogens. Facility staff failed cover kitchen waste containers when not in actual use to deter the attraction of pests and rodents. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 66. 1. Review of the facility's Food Receiving and Storage policy, dated 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; -Uncooked and raw animal products and fish…

    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 · F2024-08-09 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 66. 1. Review of the facility's policies showed staff did not provide a policy in regard to the qualifications of the Infection Preventionist. 2. During an interview on 08/08/24 at 12:22 P.M., Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) said he/she enrolled in the required IP training Monday night or Tuesday morning after the DON put his/her notice in. The LPN/ADON said he/she is not a trained IP. During an interview on 08/08/24 at 12:44 P.M., the administrator said the former Director of Nursing (DON) had been enrolled in the IP training since hired back in April and had not completed the course prior to turning in his/her resignation on Monday. The Administrator said the ADON and another Registered Nurse (RN) who works at the facility are now enrolled in IP training, so 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-09 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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, facility staff failed to ensure Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) were completed for three (Resident #25, #48 and #59) of seven sampled residents. The facility census was 66. 1. Review of the facility's PASARR Procedure policy, undated, showed staff are instructed as follows: -Regardless of source of payment and on the day of acceptance of the referral the Clinical Liaison will request a completed DA-124 A/B (form for the PASARR), a federally mandated screening process for individual with serious mental illness and/or mentally regarded/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility; -If the DA-124 forms are received from a referral source prior to admission: a. If the resident does not trigger for a Level II screening and is not applying for Medicaid but…

    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 · E2024-08-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items placed in hot holding at 140º F or higher. Facility staff also failed to reheat pureed food items to an internal temperature of 165 degrees Fahrenheit (º F) before service to prevent the growth of food-borne pathogens and potential for food-borne illness. These failures have the potential to affect all residents who dined in one of two dining rooms. The facility census was 66. 1. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Food service employees shall prepared and serve food in a manner that complies with safe food handling practices; -The danger zone for food temperatures is between 41º F and 135º F . This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness; -The longer foods remain in the danger zone the greater the risk for growth of harmful…

    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 · E2024-08-09 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 prepare and serve food items at an appropriate texture for 10 of 10 residents (Residents #9, #20, #24, #25, #29, #32, #47, #48, #51 and #58) who received dental/mechanical soft diets. The facility census was 52. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. Review of the facility's Standardized Recipes policy, dated April 2007, showed the policy directed standardized recipes shall be developed and used in the preparation of foods and only tested, standardized recipes will be used to prepare foods. Review of the facility's recipe for Ground Cheeseburger on Bun, dated 2002, showed the recipe direct staff to place one prepared hamburger patty per serving into the food processor and grind into small pieces. Review showed the recipe directed staff to place a #10 (3.2 ounce) scoop of the ground hamburger patty and one ounce of cheese on a hamburger bun for service. Review 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. This had the potential to affect all residents at the facility. The census was 68. 1. Review of the facility's Sufficient Nursing Staff policy, dated October 2022, showed The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Review of the Facility Assessment, dated 11/1/22, showed the following: -The fluctuations in census and acuity may impact staffing needs; -One DON Registered Nurse (RN) full time; -One RN on the dayshift. -Two licensed practical nurse (LPN) for each shift. -Two nursing staff with Administrative duties on the dayshift; -Dayshift is identified as 7:00 A.M. to 7:00 P.M. and Nightshift is identified as 7:00 P.M. to 7:00 A.M. Review of the facility's nursing schedule dated 4/16/23 through 5/18/23 showed the following: - On 4/16/23, the DON served as the charge nurse during the dayshift. The census was 70; -…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-05-19 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, facility staff failed to prepare food according to recipes and to ensure residents with pureed diets received all items on the menu. This failure had the potential to affect all facility residents. The census was 68. 1. Review of the facility's Meatloaf recipe, undated, showed staff were directed to use 16 ¾ pound (lb) of ground beef for 67 three-ounce servings. Observation on 5/17/23 at 9:44 A.M., showed [NAME] M prepared meatloaf for the residents' lunch meal. Further observation showed [NAME] M added 15 lb of ground beef to the meatloaf mixture. Staff served the meatloaf to the resident's for lunch. During an interview on 5/17/23 at 9:48 A.M., [NAME] M said the recipe called for 17 ½ lb of ground beef, but he/she thought it was too much. The cook said 15 lb would be enough ground beef. 2. Review of the facility's Creamed Corn recipe, undated, showed residents on mechanical soft diets were to receive creamed corn with margarine. Observation on 5/17/23 at 10:39 A.M., showed [NAME] M prepared mechanical soft corn for 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-05-19 · 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, interviews, and record reviews, the facility staff failed to ensure the ice machine drained through an air gap, to properly store open food to prevent cross contamination and outdated usage, and to maintain the kitchen in a clean and sanitary manner. The facility staff also failed to perform hand hygiene as often as necessary. The census was 68. 1. Review of the facility's policies and procedures showed the facility did not have a policy on the inspection and maintenance of the ice machine. Observation on 5/16/23 at 2:00 P.M., showed the ice machine, located in the kitchen, did not drain through an air gap. Further observation showed staff served the ice to residents throughout the day. During an interview on 5/16/23 at 2:03 P.M., the maintenance director said he was not aware the ice machine should drain through an air gap. He said the ice machine has been like that for years. During an interview on 5/19/23 at 11:21 A.M., the dietary manager (DM) said the maintenance director was responsible to clean and maintain the ice machine. The DM said he/she had not…

    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 · Ecited before2023-05-19 · tag F0658 — failed to meet professional standards of care — pattern
    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, facility staff failed to meet professional standards of care when staff failed to obtain and document weights for four residents (#12, #20, #30, and #67). The facility census was 68. 1. Review of the facility's Weight and Measuring the Resident policy, dated March 2011, showed: -The purpose is to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident; -Weight is usually measured upon admission and monthly during the resident's stay; -The weight should be documented in the medical record; -If the resident refused the weight, it should be documented in the medical record; -Report significant weight loss/gain to the nurse supervisor. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/21/23, showed facility staff assessed the resident as: -Unable to complete cognitive assessment; -Diagnosis of asthma, kidney…

    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 · E2023-05-19 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 facility staff failed to assist five out of 17 sampled dependent residents (Resident #8, #25, #29, #41, and #56) with grooming and bathing, and failed to assist three dependent residents (Resident #18, #35, and #62) during meals. The facility census was 68. 1. Review of the facility's policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan fare, including appropriate support and assistance with: a.…

    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 · E2023-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when they failed to properly propel four residents (Resident #13, #18, #68 and one unknown resident) in wheelchairs in a manner to prevent accidents, failed to ensure hazardous chemicals were stored in a safe manner, and failed to provide safe mechanical lift transfers for one resident (Resident #8). The facility census was 68. 1. Review of the facility policies showed the facility did not provide a policy for wheelchair safety. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/6/23, showed staff assessed the resident as: -Cognitively impaired; -Used a wheelchair. Observation on 5/16/23 at 12:24 P.M., showed dietary aide M propelled the resident to the dining room table without pedals on the wheelchair. The resident's heels touched the floor. During an interview on 5/16/23 at 12:32 P.M., the dietary aide M said…

    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 · Ecited before2023-05-19 · 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 observation, interview, and record review facility staff failed to store and label medication in a safe and effective manner for two sampled medication carts and one medication storage room. The facility census was 68. 1. Review of the facility's Storage of Medications policy, dated April 2017, showed staff are directed as follows: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received; - Drug containers that have missing, incomplete, improper, or incorrect labels hall be returned to the pharmacy for proper labeling before storing; - Medications requiring refrigeration must be store in a refrigerator located in the drug room at the nurses; station or other secured location under proper temperature controls. - The facility shall not used discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 2. Observation on 05/17/23 at 8:38 A.M., showed Certified Medication Aide (CMT) L retrieved a medication cup with pre-popped unidentified…

    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 before2023-05-19 · 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

    Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene during incontinence care for one resident (Resident #9) and failed to use appropriate hand hygiene before and after medication administration for 10 residents (Resident #6, #7, #8, #15, #16, #31, #33, #44, #45, and #48). The facility census was 68. 1. Review of the facility's Hand Hygiene policy, dated 2017, showed: -appropriate hand hygiene is essential in preventing transmission of infectious agents; -hand hygiene continues to be the primary means of preventing the transmission of infection; -Hand hygiene (e.g., handwashing and/or Alcohol Based Hand Rub (ABHR): consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when: hands are visibly soiled, before eating and after using the restroom; -Wash hands with soap and water when hands are visibly dirty or…

    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 · E2023-05-19 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal pneumonia (infection caused by bacteria) in accordance with national standards of practice for four (Residents #9, #41, #42 and #55) of six sampled residents. The facility census was 68. 1. Review of the facility's Resident Immunization and Vaccinations policy, revised 12/01/22, showed: -The pneumococcal vaccine program as recommended by the Center for Disease Control and Prevention (CDC) varies for patients by age group. The recommendations, updated in 2022, are as follows: -Follow current CDC recommendations for vaccination schedules and dose; -Nursing Procedure: --Upon admission, follow CDC guidelines to assess immunization eligibility requirements; --If the resident is eligible, provide education to the resident or the resident's representative regarding the benefit and potential side effects of the immunization. Offer the immunization; --If…

    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 · D2023-05-19 · 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 observation, interview and record review, facility staff failed to plan interventions and update the care plan; failed to complete a Braden scale assessment (tool to assess risk for developing pressure injury) for three weeks after admission; failed to document a weekly skin assessment on 5/5/23; failed to document measurements, appearance, odor, pain, or presence of drainage of the wound; and failed to consult with the dietician regarding the presence of a new unstageable pressure injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) wound for one resident (Resident #9). The facility census was 68. 1. Review of the facility's Pressure Injury Prevention and Management Policy, dated October 2018, showed: -The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable; -Avoidable is defined as development of a pressure injury/ulcer and 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
  • No harm found · C2026-03-13 · tag F0575 — widespread
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    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 post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA) in an accessible location for residents and visitors to view in the memory care unit. The census was 62.1. Review of the facility's policy titled, Facility Postings, undated, showed facility staff will post the required postings in an area accessible to all staff and residents. Facility postings should include a list of names, addresses (mailing and email), and a telephone number of all pertinent state agencies including the SA. Observation on 03/10/26 at 10:30 A.M., showed staff did not post the name, address, and toll-free telephone number for the Elder Abuse Hotline in an accessible location on the memory care unit for residents or visitors to use if needed. Observation on 3/13/26 at 11:00 A.M., showed staff did not post the name, address, and toll-free telephone number for the Elder…

    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

“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

No federal fines in the current CMS record.

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 →

RatingThis homeChain avg
Overall 1 of 53.3-2.3 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 1 of 52.8-1.8 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 / managerTypeRoleShareSince
LIERMAN, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 03/12/2008
MILLER, BETHIndividualCORPORATE OFFICERsince 01/17/2023
BRIDGE REHABILITATION INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2024
BUSEY CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/10/2023
ELDERCARE MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/12/2008
BARNES, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2013
CIEGEL, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2022
DOERHOFF, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2021
KNIGHT, KARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2018
MCBRYANT, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/04/2024
THAYER, JEANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2021
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/25/2016
LIERMAN FAMILY CO VII, LLCOrganizationADP OF THE SNFsince 05/01/2008
WIPFLI LLPOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 25 rows in the source record cover these 14 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.

$5.1M
Net patient revenuemost recent cost report
-1.9%
Operating marginrevenue minus expenses
$802K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 4%Other / private 24%

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $802K paid to related parties — landlords or management companies under common ownership — equal to about 16% 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.

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

$222per resident / day
operating cost
$6,745per month
≈ monthly operating cost
$218per 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

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.

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 265208. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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.

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