Seasons Rehab And Healthcare Center
15600 Woods Chapel Road, Kansas City, MO 64139 · For profit - Limited Liability company · 78 certified beds · (816) 478-4757 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0606), cited Jun 2021
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (58%) 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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 25.1% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 98.9% | 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 | 5.5% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 28.3% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.8% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.3% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 12.9% | 2.2% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.82 | 2.33 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Met the expected recovery: 40.9% 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 22 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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
| 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.0–17.0 | 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 | 40.9% | 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 | 31.8% | 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 | 22.7% | 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 | 88.0% | 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 | 0.0% | 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 | 6.6%CMS range 3.5–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 78 beds and averages 72.3 residents a day — about 93% occupied, or roughly 6 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.27 hrs/resident/day on weekends vs 3.92 on weekdays — 17% thinner on weekends. RN hours go from 0.44 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · E2026-02-11 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the administration of the facility failed to safeguard the medication administration of each resident. The administration failed to provide Certified Medication Technician (CMT) A his/her own sign in to pass medications once notified the sign on was not working. CMT A used Licensed Practical Nurse (LPN) A's sign in to pass medications to the facility residents. This has the potential to affect all residents. The facility census was 74 residents.Review of the facility undated Onboarding Standard Operating Procedure showed:-Interview applicant. -If an offer is made and accepted proceed to the next step.-Collect all necessary documents to run necessary background and license checks.-Start new hire onboard electronically through Hosted Time.-Preferably while they are in the office.-All new hires must complete new hire documentation electronically.-Run all necessary background checks while new hire is completing onboarding via Host Time.-All the above steps should be performed as timely as possible before a new hire leaves the facility. Review of 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.
- Potential for harm · E2026-02-11 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff-maintained documentation of medications as provided on the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for eight sampled residents ( Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9), when Certified Medication Technician (CMT) A used Licensed Practical Nurse (LPN) A's electronic sign in when he/she administered resident's medications for three months for eight of the nine sampled residents. The facility census was 74 residents.Review of the facility revised Medication Administration Policy dated 10/24/22 showed:-Purpose.--To provide practice standards for safe administration of medications for the residents in the facility.-Procedure.--The Licensed Nurse or CMT will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR.-Documentation.--The time dose…
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 · E2025-01-31 · tag F0732 — patternPost nurse staffing information every day.
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 post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift in locations throughout the facility for view by residents, family members and visitors. The facility census was 74 residents. Record review of the facility Staffing, Schedule and Postings policy dated 10/24/2022 showed: -The facility would post the current date, the total number and the actual hours worked by licensed (RNs and LPNs) and unlicensed (CNAs) nursing staff directly responsible for resident care per shift, and the facility resident census. 1. Record review of the Staffing Ratio and Census Reports dated 12/27/24 through 1/27/25 showed: -The number of RNs, LPNs, CNAs and CMTs for each 24 hour period, rather than for each eight hour shift. -The staffing sheets did not show the total number of hours for RNs, LPNs, CNAs and CMTs for each eight hour shift. Observation of the posted…
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 · D2025-01-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 two sampled residents (Residents #40 and #55) out of three sampled residents, who were notified their Medicare Part A coverage would likely end and had benefit days remaining, were provided the Quality Improvement Organization (QIO) contact name and toll free phone number on their Notice of Medicare Non-Coverage (NOMNC), Centers for Medicare (CMS)-10123 form. On 1/31/25 the Administrator was notified of the past non-compliance which took place for a period of months that started on or before 7/9/24 and went through 12/31/24. On 1/2/25 the Social Services Director was given an updated Form CMS-10123 containing the QIO contact name and toll-free number so residents could appeal the decision to end services. On 1/2/25 the Social Services Director received education from Regional Nurse Consultant A on providing the QIO contact name and phone number to residents with benefit days remaining whose services were expected to end. The deficiency was corrected on 1/2/25. Review of the facility's Medicare Denial Process policy,…
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 · D2025-01-31 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 an ongoing program of activities to meet the needs of two sampled residents (Residents #49 and #176) who didn't like to go to group activities and were dependent upon staff to provide activities for mental, physical, and psychosocial stimulation out of 18 sampled residents. Additionally, the facility failed to ensure there was a way to easily access daily activity participation over time. The facility census was 74 residents. Review of the facility's Activities Program policy, revised 10/24/22, showed: -The purpose of the policy was to encourage resident participation to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable residents to maintain the highest attainable social, physical, and emotional functioning. -After completion of the initial Activity Assessment and the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 behaviors and develop a care plan that included target behaviors (specific behaviors of the resident), and relevant non-pharmacological approaches for one sampled resident (Residents #49) who was prescribed a psychotropic medication (a drug that affects brain activities associated with mental processes and behaviors). The facility census was 74 residents. Review of the facility's Behavior Management policy, undated, showed key components of behavior management included: -Identifying residents whose behaviors may pose a risk to self or others. -Develop individualized and practical care strategies based on assessed needs. -Implement a behavior management program. -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including effectiveness of psychoactive drugs. -Nursing staff will document the response to medication, including behaviors and the side effects on the Medication Administration…
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 before2024-08-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to assess a resident who had fallen before moving him/her and did not call Emergency Medical Services (EMS) in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 77 residents. The Administrator was notified on 8/26/24 of Past Non-Compliance (PNC) which occurred on 8/20/24. On 8/20/24 facility administration identified the resident was moved after a fall prior to being assessed by a licensed nurse and the delay in emergency services being notified to transfer the resident to the hospital. The facility completed the investigation, and the facility staff were in-serviced by 8/21/24. Review of the facility's policy, Response to Falls, dated October 24, 2022 showed: -Residents who have experienced a fall would have been promptly assessed and treated for injuries. -After each fall, a Licensed Nurse would have completed a Post-Fall Assessment and Investigation. -Immediate Post Fall Response: -Upon…
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 · Fcited before2023-05-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 keep the walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils and to ensure the proper refrigeration, and/or disposal of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 76 residents with a licensed capacity for 78 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 5/17/23 between 8:56 A.M. and 12:19 P.M. showed the following: -There was a wooden rolling pin in the center food preparation table drawer that had food residue on it. -The gasket on the door to the reach-in refrigerator was…
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 · Fcited before2023-05-23 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 2. Review of the facility's Tuberculosis Screening policy dated 10/24/22 showed: -Facility staff were screened for TB as part of the requisite employee health examination. -There were no specific instructions on the procedure of TB screening. Review of the facility's Administration and Interpretation of TB Skin Tests (TST) policy dated 10/24/22 showed: -Screening of facility staff for TB was done upon hire. -A licensed nurse or healthcare practitioner interpreted the TST 48 to 72 hours after administration. Review of the facility's undated Onboarding Standard Operating Procedure showed: -A TST must be read and documented within 48-72 hours from when it was administered. -No employee could start working prior to the reading of the first TST. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 3/4/23. -Employee B was hired on 4/10/23. -Employee C was hired on 1/21/23. -Employee E was hired on 4/1/23. -Employee G was hired on 1/27/23. 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.
- Potential for harm · E2023-05-23 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) for 10 out of 10 sampled new staff and to follow their policy to check the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for seven out of 10 sampled new staff. The facility census was 76 residents. Review of the facility's undated Onboarding Standard Operating Procedure showed: -Instructions to run all necessary background checks (Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees)) while a new hire was completing their onboarding. -The NA registry check and the FCSR were some of the required checks under the background checks bullet point. Review of the facility's Staff Screening policy dated 10/24/22 showed: -Prior to employment, the facility would verify and document a CBC and state exclusion…
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 13 citations
- Potential for harm · Dcited before2023-05-23 · 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 observation, interview, and record review the facility failed to ensure parameters were in place for the nursing staff to safely administer Metoprolol (a medication used to treat high blood pressure) and other blood pressure medications for three supplemental residents, (Resident #44, Resident #74, and Resident #10), and to ensure parameters were in place for the nursing staff to safely administer Digoxin (a medication used to treat heart failure and heart rhythm problems) for one supplemental resident (Resident #44) out of three supplemental residents for medication pass. The facility census was 76 residents. Review of the Mayo Clinic precautions for Digoxin (Oral Route Precautions), dated 5/1/23 showed: -Side effects include; dizziness, fainting, fast, pounding or irregular pulse, or slow heartbeat. -The nurse should take an apical (a measurement that takes place when a person is sitting or lying down by placing a stethoscope (a medical instrument used to listen to sounds produced within the body) on…
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 · D2023-05-23 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide restorative care (a program to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) following discharge from therapy services for one sampled resident (Resident #8) out of 18 sampled residents. This deficient practice had the potential to effect all residents who were discharged from therapy services to a restorative program. The facility census was 76 residents. Review of the facility's Restorative Nursing Program Guidelines policy, dated 10/24/2022, showed: -The program focused on achieving and maintaining physical, mental and psychosocial functioning. -A resident started the Restorative Nursing Program when a resident was discharged from formalized physical, occupational or speech rehabilitation therapy. -The Director of Nursing Services (DSN) managed and directed the Restorative Nursing Program. -General restorative nursing care did not require the use of qualified professional therapists to render such care. The basic…
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 · Fcited before2021-06-28 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were tested and/or screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled residents (Residents #14, #21, #27, #55 and #56) out of five residents sampled and to wash or sanitize hands between glove changes during wound care for one sampled resident (Resident #50) out of 18 sampled residents. Additionally, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all…
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 · E2021-06-28 · tag F0606 — failed to not employ staff found guilty of abuse — patternNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry for two out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 73 residents. 1. Record review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A, a housekeeping supervisor, was hired on 12/21/20. -Employee C, a dietary worker, was hired on 2/22/21. Record review of the above employees' employee files showed no check of the NA Registry to ensure they did not have a Federal Indicator prohibiting them to work in a certified facility. During an interview on 6/28/21 at 10:00 A.M., the Administrator said: -The Human Resources employee was responsible for completing the NA registry checks. -He/she didn't know NA registry checks were required on non-nursing staff. During an interview on 6/28/21 at 10:11 A.M., the Human…
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 · E2021-06-28 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 ensure the resident's medications were kept in a clean, sanitary, and secured medication cart or medication room, to ensure expired medications were destroyed/discarded, to ensure opened medications had the date they were opened written on the container, failed to ensure there was no food stored in with the medications, to ensure there were no cleaning supplies being stored/kept in the medication drawer, to ensure medications were removed from the medication cart when a resident discharged from the facility in two out of four medication carts, one treatment cart, and one medication room, and failed to ensure medications were labeled and matched the physician's order for one resident (Resident #500) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Medication Storage in the Facility, dated 11/18 showed: -Medications and biologicals were stored safely, securely, and followed the manufacturer's recommendations or those of the supplier. -Potentially…
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 before2021-06-28 · 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 keep the walk-in refrigerator floor clean; to retain a thermometer in the walk-in freezer to confirm correct temperatures; to safeguard plastic cutting boards were in good condition to avoid food safety hazards; to separate damaged food stuffs; and to ensure the proper refrigeration or disposal of food products. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 73 residents with a licensed capacity for 78. 1. Observations during the initial Kitchen inspection on 6/21/21 between 9:05 A.M. and 1:31 P.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 pound (lb.) 6 ounce (oz.) can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. -In the walk-in refrigerator, there was a plastic lid under a rack. -There was no thermometer in the walk-in freezer. -The brown, red, white, and green cutting boards heavily scored to the point 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 · D2021-06-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress setting following manufacturer's guidelines and to ensure a Broda chair (a specialized tilt in space wheelchair used for comfort and positioning) was the appropriate size for one sampled resident (Resident #21) out of 18 sampled residents. The facility census was 73 residents. 1. Record review of Resident #21's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Cerebral Infarction (stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). -Rheumatoid Arthritis with rheumatoid factors (a chronic progressive disease causing inflammation in the joints 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 · D2021-06-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 accurately document the wishes of a resident to be a Do Not Resuscitate (DNR a legal order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person) if that person's heart stops beating) for one sampled resident (Resident#44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Cardio-Pulmonary Resuscitation (CPR) dated [DATE] showed: -Residents may elect to execute an advanced directive to have CPR withheld in the event of a cardiac or respiratory arrest. -CPR may be withheld or stopped once it has been determined the resident had such an order. -Residents without an executed advanced directive or who had…
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 · D2021-06-28 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 maintain one sampled resident's (Resident #219) dignity by allowing the bottom half of the resident to be exposed during cares and to attempt to provide privacy for one sampled resident (Resident #50) who had removed his/her shirt in the day area of the unit out of 18 sampled residents. The facility census was 73 residents. Note: A policy related to resident dignity was requested from the facility Director of Nursing (DON) on 6/28/21 and he/she reported that the facility had no such policy. 1. Record review of Resident #219's undated face sheet showed the resident had the following diagnoses: -Dementia without behaviors (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -Malignant neoplasm of female genital organs (cancer of female genital organs excluding the uterus and ovary). -Malignant neoplasm of vulva (cancer that occurs on the outer surface of female genitals).…
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 · D2021-06-28 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
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 adequately prepare one resident for a planned surgery by not ensuring the resident was kept Nothing by Mouth (NPO) which resulted in the surgery having to be rescheduled for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy, titled Physician Orders, dated 10/28/15 showed: -Physician orders were obtained and carried out in a systematic, organized fashion so resident care could be provided in a safe and consistent manner. -Once an order was received, it must be carried out as soon as possible. -Carrying out the order consisted of, but was not limited to, transcribing the order and notifying other applicable departments. 1. Record review of Resident's #44 face sheet showed the resident was readmitted to the facility on [DATE] with the following diagnoses: -Dementia without behaviors (a group of thinking and social symptoms that interferes with daily functioning.…
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 before2021-06-28 · 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 observation, interview and record review, the facility failed to complete weekly weights as ordered for one sampled resident (Resident #5) and to schedule a Computed Tomography scan (CT-provides detailed images of internal organs) as ordered for one sampled resident (Resident #6) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's physician orders policy dated 10/28/15 showed: -All general guidelines for obtaining physician orders applied to nutritional/dietary and diagnostic testing orders. -The nurse was responsible for contacting the provider who will be performing the diagnostic test to make an appointment. 1. Record review of Resident #6's care plan dated 12/31/20 showed the resident: -Required assistance with his/her daily cares related to impaired cognition due to Alzheimer's disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills). -Had high blood pressure. -Was at risk for falls. 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 before2021-06-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent three near falls for one sampled resident (Resident #50); and to ensure one sampled resident (Resident #319) received his/her morning medications out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's Accidents and Incidents policy dated 2/13/20 showed: -The facility should assess each resident's risk of an accident including the need for supervision. -Interventions should be implemented to prevent accidents including adequate supervision. 1. Record review of Resident #50's skin note dated 3/31/21 showed: -The resident rolled out of his/her bed and onto his/her fall mattress. -It was care planned that the resident would lie on the mattress on the floor at his/her will. Record review of the resident's nurse's note dated 4/13/21 showed the resident was on the floor in the dining room, on his/her right side next to his/her Broda chair (a wheelchair that can…
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 · D2021-06-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and care by not obtaining physician ordered laboratory tests for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Physician Orders, dated 10/28/15 showed: -Physician's orders were to be obtained and carried out in a systematic, organized fashion so that resident care could be provided in a safe and consistent manner. -Once obtained the order must be carried out as soon as possible. -In the event an order could not be implemented the nursing staff must notify the physician who wrote the order to discuss care alternatives. 1. Record review of Resident #44's face sheet showed the resident was admitted on [DATE] then readmitted on [DATE] with the following diagnoses: -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders,…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to AMA HOLDINGS — 13 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 | 1.6 | +2.4 vs chain |
| Health inspection | 4 of 5 | 2.3 | +1.7 vs chain |
| Staffing | 2 of 5 | 1.2 | +0.8 vs chain |
| Quality measures | 3 of 5 | 2.3 | +0.7 vs chain |
The other 12 homes this chain runs (chain average 1.6★, 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 |
|---|---|---|---|---|
| MO OPERATION HOLDINGS DE SPE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 99% | since 01/25/2024 |
| AMA HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/19/2021 |
| DEF HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/19/2021 |
| MARX, ASHER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 10/19/2021 |
| WOLF, JACQUES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | NO PERCENTAGE PROVIDED | since 10/19/2021 |
| MOORE, ANGELA | Individual | W-2 MANAGING EMPLOYEE | — | since 10/19/2021 |
CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 82% 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 $885K paid to related parties — landlords or management companies under common ownership — equal to about 13% 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
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 265850. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-31, 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.