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Abbey Senior Health

206 North Main Street, O Fallon, MO 63366 · For profit - Limited Liability company · 55 certified beds · (636) 240-5754 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2025
  • it has 1 actual-harm citation
  • 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 score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

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

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1055 E Terra Ln · (636) 272-6161 · Call to confirm hours
Pharmacy
920 N Main St · (636) 379-2636 · Call to confirm hours
Grocery
ALDI0.8 mi
8615 Veteran's Memorial Dr. · (855) 955-2534 · Call to confirm hours
Park
308 Civic Park Dr · (636) 474-2732 · Typically dawn to dusk
Place of worship
204 N Main St · (636) 240-3420

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 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 improved from 2 to 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.

Overall rating3★
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 increased30.1%18.1%15.4%worse
Long-stay residents who lose too much weight2.0%5.3%5.4%better
Long-stay residents with a catheter left in their bladder1.9%1.1%0.9%worse
Long-stay residents with a urinary tract infection8.0%2.3%2.0%worse
Long-stay residents with depressive symptoms3.1%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 injury8.1%4.1%3.3%worse
Long-stay residents whose ability to walk worsened24.9%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.3%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%90.9%95.3%typical
Long-stay residents with pressure ulcers4.4%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control18.9%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.4%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine81.5%63.5%79.4%typical
Short-stay residents rehospitalized after admission25.8%26.0%22.6%worse
Short-stay residents with an outpatient ER visit9.5%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.952.111.67worse
Long-stay outpatient ER visits per 1,000 resident days1.222.331.80better

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.

56.9% 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 272 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.9%U.S. median 51.5%
Got home and stayed home
12.7%U.S. median 10.7%
Went back to hospital
49.3%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 49.3% 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 69 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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 SNF56.9%CMS range 49.1–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.7%CMS range 9.4–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge49.3%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 discharge34.8%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 discharge36.2%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 identified82.1%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 discharge88.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%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 worsened1.2%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 hospitalization6.5%CMS range 4.2–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

0.73
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.94
Aide hours/ resident / day
4.74
Total nurse hours/ resident / day
0.47
RN hoursweekends
35.6%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 55 beds and averages 50.4 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 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 4.10 hrs/resident/day on weekends vs 4.99 on weekdays — 18% thinner on weekends. RN hours go from 0.84 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below 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

9
deficiencies at the latest standard inspection (2024-10-25)
13
at the previous standard inspection (2023-06-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2023-06-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview, and policy review, the facility failed to ensure seven residents (Resident (R) 3, R207, R27, R31, R22, R39, R52, and R40) of 24 sampled residents remained free of accidents/hazards and received adequate supervision to prevent accidents. The facility failed to ensure coffee that was accessible to residents and served to residents was within a safe temperature range. On [DATE], R3 spilled coffee on her lap resulting in blisters on both sides of her inner thigh, and on [DATE], R40 spilled coffee on his lap. The Director of Nursing (DON) failed to ensure R207, R27, R31, R22, R39 and R52, who had falls, lacked adequate supervision, a comprehensive fall investigation after each fall, and remained free from injury. Findings include: 1. The policy titled Safety of Hot Liquids revised 10/2014 revealed resident will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-11 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to communicate transfers and/or discharges to the State Long-Term Care Ombudsman (a trained advocate, often a volunteer, who works to protect the rights and improve the quality of life for residents in long-term care facilities, such as nursing homes and assisted living facilities) for three residents (Resident #44, #70 and #34), in a review of 14 sampled residents, and for two discharged residents (Residents #4 and #38). The facility census was 49. Review of the undated facility policy, Transfer and Discharge from the Facility, showed the following:-The facility forwards a copy of all discharge notices to the Office of the State Long-Term Care Ombudsman;A. Facility staff will document in the residents' record:iv. Date copy of the notice was sent to the representative of the Office of the State Long-Term Care Ombudsman per requirements.1. Review of email communication from the State Long-Term Care Ombudsman, dated 06/05/26 at 4:14 P.M. and 06/08/26 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 one resident (Resident #1), in a review of five sampled residents, remained free from misappropriation of property. Certified Nurse Aide (CNA C) took the resident's wallet containing cash and the resident's debit card without the resident's knowledge or permission and used the debit card to pay Instant Credit Auto $450.00 (loan company for car loans), Spectrum (an internet and cable provider) $378.00 and $139.29 at Five Below (a retail store). The facility census was 53. On 9/11/25 at 12:30 P.M. the administrator was notified of the past non-compliance which occurred on 9/5/25. On 9/8/25, the administrator became aware of the violation of misappropriation of the resident's debit card and cash by CNA C when the resident logged onto his/her bank account and found the money had been withdrawn from the account. CNA C was an agency aide, and the agency was notified on 9/8/25 that the aide could not return to the facility. Staff were in-serviced 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2024-12-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 one resident (Resident # 1 ) in a review of eleven residents was free from verbal and mental abuse when Dietary Aide E threw a ceramic dinner plate towards the resident, hitting the wall behind the resident, shattering the plate and called the resident a fucking bitch. The facility census was 50. On 12/19/24 at 11:00 A.M. the administrator was notified of the past non-compliance which occurred on 12/15/24. On 12/15/24 the administrator identified Dietary Aide E verbally and physically abused Resident #1. Upon discovery, staff suspended Dietary Aide E, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff was educated on the facility abuse and neglect policies. Dietary Aide E was terminated. The deficiency was corrected on 12/16/24. Review of the facility abuse policy, dated July 2017, showed the following: -It was the policy of the facility that all residents are to be free from abuse or neglect of a physical, emotional, verbal or sexual…

    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 · Past Non-Compliance
  • Potential for harm · F2024-10-25 · 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 failed to store, prepare, and serve food to residents in a safe and sanitary manner when staff failed to employ proper hand hygiene and gloving practices and failed to store food in a manner that prevented potential contamination. Staff failed to ensure beverage and ice machines were clean and an air gap was present at ice machine drains. Staff failed to document and demonstrate knowledge of the use and testing parameters of the facility's dishwashing machines to ensure dishes were cleaned and sanitized properly. The facility census was 49. Review of the facility policy, Food and Nutrition Services Staff, revised November 2022, showed the following: -Food and nutrition services staff should wash their hands before serving food to residents; -Employees should wash their hands after collecting soiled plates and food waste and prior to handling food trays; -Bare hand contact with food is prohibited; -Gloves are worn when handling food directly and changed between tasks. Review of the undated facility policy, Procedures…

    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 · E2024-10-25 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    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 residents were aware of posted resident rights in an easily accessible area for review at their leisure. The resident census was 49. Review of the facility's policy, Resident Rights, revised February 2021 showed the following: -Federal and state laws guarantee certain basic rights to all residents of the facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Be informed about his or her rights and responsibilities; -Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter; -Copies of resident rights are posted throughout the facility. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said they did not know where the resident rights were posted in the facility. Observation on 10/23/24 at 10:45 A.M., showed the resident rights posted along…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-25 · tag F0574 — pattern
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily accessible and could be read by residents in the facility without assistance. The facility census was 49. Review of the facility's policy, Filing Grievance/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file a grievance, either orally or in writing, to the facility staff or the agency designated to hear grievances (e.g. the State Ombudsman); -A copy of the grievance/complaint procedure is posted on the resident bulleting board. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said the following: -They knew what the Ombudsman program was but was unaware of who their representative was or how to contact them; -They did not know how to contact the State Survey Agency if they had any concerns. Observation on 10/23/24 at 10:45 A.M.,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-25 · 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, the facility failed to ensure staff safely transported residents in wheelchairs for four residents (Residents #26, #27, #25, and #4), in review of 19 sampled residents, and for two additional residents (Residents #11 and #40). The census was 49. During an interview on 11/05/24 at 10:19 A.M., the Director of Nursing (DON) said the facility did not currently have a policy for transporting residents in wheelchairs or the use of wheelchair foot rests. 1. Review of Resident #26's undated face sheet showed the resident's diagnoses included difficulty in walking, unsteadiness on feet, psychoactive substance-induced sleep disorder, history of falls, major depression, anxiety disorder, and mild cognitive impairment. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/25/24, showed the following: -Severe cognitive impairment; -Impaired range of motion to one side of the lower…

    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 · E2024-10-25 · tag F0700 — pattern
    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, the facility failed to ensure bed rails assessments were consistent with facility policy to evaluate the resident's risk for entrapment and failed to conduct ongoing assessments to ensure the proper use and safety of the bed rails for eight residents (Residents #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include: side rails, safety rails, and grab/assist bars; -The use of bed rails or side rails (including temporarily raising…

    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 before2024-10-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for eight residents (Residents #24, #12, #39, #27, #102, #103, #202, and #42), in a review of 20 sampled residents. Staff failed to failed to utilize Enhanced Barrier Precautions (EBP) during personal care for three residents (Residents #24, #12, and #39) who had urinary catheters (a tube inserted into the bladder to drain urine); failed to maintain a system to ensure one resident's (Resident #24's) urinary catheter tubing and dignity bag (containing the urinary drainage bag) were kept off the floor; failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #27); failed to ensure nebulizer masks (mask used to administer breathing treatments) and CPAP (a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in 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 · E2024-10-25 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Resident #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · F2023-06-09 · tag F0835 — failed to run the facility competently — widespread
    Administer 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 record review, observation and staff interview, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: Review of the Facility Assessment updated 11/2021 for 2022, revealed, Quality Assurance overall has been delegated as a top oversight priority of our new DON (Director of Nursing). The Q1/A (Quality Improvement/Assurance) process, its' administration and report to the QA Committee and Administrator about progress, problem areas and trouble shooting [sic] will be an outgrowth of weekly UR/High Risk meetings, Monthly QA review and quarterly meetings. PCC OL/A Module has enabled better monthly tracking of Q/A measured data. The Administrator and DON failed to ensure coffee was not accessible to residents and was served to residents within a safe temperature. Specifically, R3 spilled coffee on her lap on 05/18/23 which caused blisters on both sides of her inner thigh 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-06-09 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 Facility Assessment was maintained accurately. Specifically, the Facility Assessment had not been reviewed/revised annually and did not accurately reflect the current resident population. Findings include: Review of a facility policy titled, Facility Assessment, revised October 2018, revealed, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. This policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes . c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with . (4) cognitive or behavioral impairments. This policy further revealed, The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. The administrator. The policy further revealed, The facility assessment includes a detailed review of the resident…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-09 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to ensure the activities program was directed by a qualified activities professional. Specifically, the current Activities Director was not a qualified activities professional who was licensed or registered by the state. Findings include: Review of the Extended Survey Book provided by the Administrator on 06/08/23, revealed the current Activities Director (AD) was not licensed or certified. During an interview with the Administrator, on 06/08/23 at 4:30 PM, he stated the current AD was not certified. The Administrator stated he was not aware the current AD was not certified or needed to be certified. During an interview with the AD, on 06/09/23 at 8:20 AM, she stated she was not aware until 06/08/23 that she needed to be certified to supervise the activities problem. She stated she would discuss with the Administrator the process of getting certified. During an interview with the Administrator, on 06/09/23 at 10:30 AM, he stated he had registered the AD for a class to become a certified activities professional.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one (Resident (R) 32) of one resident reviewed for hospice in a total sample of 24 residents. Findings include: Review of R32's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/07/23 with medical diagnoses including Protein Calorie Malnutrition. Review of R32's Order Summary Report, located in the EMR under the Orders tab, revealed the following order, dated 04/07/23: Pro [NAME] hospice to begin 4/6/2023. Review of R32's EMR revealed no evidence that a significant change MDS was completed in response to the resident being admitted to hospice services. During an interview on 06/08/23 at 12:56 PM, the MDS coordinator (MDSC) verified R32 was admitted to hospice services and a significant change MDS should have been completed in response. The MDSC confirmed no significant change MDS was completed for R32.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a discharge assessment using the Minimum Data Set (MDS) process within the required timeframe for two (Resident (R) 11 and R47) discharged residents reviewed in a total sample of 24 residents. Findings include: 1. Review of R11's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. R11 was discharged on 12/24/22. Review of R11's MDS tab in the EMR revealed an admission MDS, with an Assessment Reference Date (ARD) of 12/13/22. The EMR revealed no evidence that a discharge MDS assessment was encoded or transmitted after the resident was discharged on 12/24/22. 2. Review of R47's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. R47 was discharged on 01/16/23. Review of MDS tab in the EMR revealed an admission MDS with an ARD of 12/31/22. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · 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, record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed for three residents (Resident (R)1, R3, and R7) of 24 sampled residents. Findings include: Review of the Facility's Policy titled Comprehensive Assessment and the Care Delivery Process dated 12/2016, revealed, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. 1. Review of R1's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses including moderate protein calorie malnutrition, dementia, age related osteoporosis, and pathological fracture. Review of R1's Physicians Orders for the month of June located in the resident's EMR under the Orders tab revealed the resident was placed on hospice…

    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 · D2023-06-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure there were weekly skin assessments completed for one resident (Resident (R) 3) of three residents sampled for skin assessments, from a total sample of 24. Specifically, the facility failed to consistently complete weekly skin assessments for R3, specifically skin assessments after blisters were identified on 05/18/23, which increased the likelihood of R3 developing a significant skin issue. Findings include: Review of the facility's Skin Tears - Abrasions and Minor Breaks, Care of policy, dated 09/2013, revealed, The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears and minor breaks in the skin . Head-to-Toe Skin Assessment to be completed by a licensed nurse weekly and recorded in the medical record .If skin breakdown noted . skin breakdown includes: burn . Charge nurse is to contact the physician for treatment orders .report new occurrence of skin breakdown to the Director of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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, record review, and facility policy review, the pharmacist failed to identify and report irregularities regarding inadequate indications for use of an antipsychotic medication for two (Resident (R) 3 and R22) of five residents reviewed for unnecessary medication use. Findings include: Review of the facility's policy titled, Medication Therapy, revised 04/2007, revealed, Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether: a. There is a clear indication for treating that individual with the medication. 1. Review of R3's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Review of R3's Order Summary Report, located in the resident's EMR under the Orders tab revealed the following order…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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, record review, and facility policy review, the facility failed to ensure psychotropic medication had an appropriate indication for use for two of five residents (Resident (R) 3 and R22) reviewed for unnecessary medication. The facility further failed to ensure that a PRN (as needed) psychotropic medication had a documented rationale for use beyond 14 days for one of five residents (R22) reviewed for unnecessary medication. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use, revised 12/2016, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The facility's policy further revealed, Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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, record review, and the facility's hospice contract, the facility failed to ensure the appropriate coordination of Hospice care by specifically failing to maintain hospice care plans, Hospice election form and Physician certification and recertification of the terminal illness specific to each patient for two (Resident (R)27, and R32) of two residents sampled for Hospice. This failure had the potential result in the interruption of the residents' coordination of care. Findings include: Review of the facility's Hospice agreement titled Nursing Facility Agreement dated 06/01/2016 reads in part Obtaining the following information from the Hospice: The most recent Hospice Plan of Care for each Hospice Patient; Hospice election form; physician certification of the terminal illness for each Hospice Patient; Names and contact information for the Hospice personnel involved in the care of each Hospice Patient; Instructions on how to access Hospice's 24 hour on call system; . Hospice medication…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-09 · tag F0880 — failed to prevent and control infections — isolated
    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, record review, and facility policy review, the facility failed to adhere to enhanced barrier precautions for one resident (R)15 from a sample of 24 residents, and failed to properly sanitize one of two glucometers on one of the two nursing units. Findings Include: Review of the facility's policy titled Enhanced Barrier Precautions dated August 2022 read in part Enhanced barrier precautions (EBPs) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; bathing/showering; transferring; providing hygiene; changing…

    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 · D2023-06-09 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and policy review, the facility failed to provide abuse prohibition training for one (Certified Nursing Assistant (CNA) 4) of five staff hired in the last six months. Findings include: Review of a facility policy titled, Resident Abuse, reviewed 07/2017, revealed Upon hiring and annually, employees will be trained on identifying resident abuse and neglect and how to go about reporting an incident. Review of an offer letter in a training file for CNA 4, provided to the survey team by Human Resources (HR), revealed a hire date of 03/11/23. Further review of CNA 4's training file revealed an abuse prohibition training dated 06/11/19. There was no evidence of any current abuse training on or after the most recent hire date of 03/11/23. During an interview on 06/09/23 at 7:58 AM, HR stated CNA 4 was a re-hire on 03/11/23. HR stated CNA 4 received abuse training on her original hire date on 06/11/19. HR stated CNA 4 stopped working at the facility on 03/08/22. HR stated CNA 4 had not received abuse training upon re-hire because she believed CNA 4 was in…

    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 · Ecited before2019-11-07 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of eight residents (Resident #2, #8, #19, #20, #23, #145, #146 and #147) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Care Plans- Baseline showed: - To assure the resident's immediate cares are met and maintained, a baseline care plan will be developed within 48 hours of admission; - The Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate needs including but not limited to: initial goals, Physician orders, Dietary orders, Therapy services and Social services; - The base line care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; - The resident…

    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 · D2019-11-07 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer for four residents (Resident #16, #23, #32, and #146) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Transfer or Discharge Documentation, showed: - When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; - The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; - When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: - The basis for the transfer or discharge; - The specific resident needs that cannot be met; - This facility's attempt to meet those needs; - The receiving…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-07 · tag F0624 — isolated
    Prepare 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 document sufficient preparation and orientation of residents to ensure safe and orderly transfer from facility to hospital in a manner that the resident can understand for four residents (Resident #16, #23, #145, and #146) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Transfer or Discharge, Preparing a Resident for, showed: - Residents will be prepared in advance for discharge; - Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. 2. Record review of Resident #16's Physician's Order Sheet (POS), dated 11/6/19, showed: - Resident admitted on [DATE]; - Diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and neuromuscular dysfunction of bladder (involved in the control of urination); - Resident is his/her own responsible party. Record review of the resident's progress…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-07 · tag F0880 — failed to prevent and control infections — isolated
    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 interview and record review, the facility failed to follow infection control protocols for tuberculosis (TB; a highly contagious communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for five residents (Resident #7, #16, #24, #29, and #32) out of 18 sampled residents. This deficient practice had the potential to affect all residents. The facility's census was 53. Record review of the Department of Health and Senior Services (DHSS) Division of Community and Public Health regulation regarding communicable diseases (19 CSR 20-20.100), showed: - Long-term care facilities shall screen their residents and staff for TB using the Mantoux method purified protein derivative (PPD) five tuberculin unit (TU) test. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all residents, employees and volunteers; - Each facility shall be responsible for ensuring that all test results are completed and that…

    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
  • No harm found · B2024-10-25 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide two residents (Residents #4 and #26), or their responsible party, with a bed hold policy at the time of transfer to the hospital, in a review of 20 sampled residents. The facility census was 49. Review of the facility's policy, Bed Hold Policy, revised May 2024, showed the following when a resident was transferred to a hospital: -Neither a resident nor the responsible party is required to pay a nursing facility to hold a bed; -If the resident/responsible person chooses to, he/she may pay a nursing facility in order to reserve the same bed the participant is leaving; -A nursing home has an obligation to inform a resident or the responsible person that paying them to hold a bed is voluntary; -When a resident is transferred to a hospital, the nursing home is required, both by Federal statute and by Federal regulation, to readmit the resident immediately upon the first availability of a bed in a semiprivate room. 1. Review of Resident #4's undated…

    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
  • No harm found · Bcited before2024-10-25 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review the baseline care plan with the resident/responsible party within 48 hours of admission or provide a copy of the baseline care plan to the resident/responsible party for two residents, (Resident #202 and #207) in a review of 20 residents. The facility census was 49. Review of the facility policy, Baseline Care Plans, revised March 2022, showed the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; -The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: -The stated goals and objectives of the resident; -A summary of the resident's medication and dietary instructions; -Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; -Any updated…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
ABBEY HEALTH GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF100%since 10/31/2018
BROWN, C CHRISTOPHERIndividualDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2018
MOUNT CARMEL SENIRO LIVING O'FALLON LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 10/31/2018
PATWARDHAN, MANISHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2020

CMS files one row per role, so the 12 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$7.6M
Net patient revenuemost recent cost report
-16.9%
Operating marginrevenue minus expenses
$1.1M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 23%Other / private 56%

This home reported $1.1M 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$514per resident / day
operating cost
$15,633per month
≈ monthly operating cost
$440per 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 265839. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-25, 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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