Friendship Village Sunset Hills
12651 Village Circle Drive, Saint Louis, MO 63127 · Non profit - Corporation · 144 certified beds · (314) 270-7777 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,433 in federal fines (most recent 2024-04-15)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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.
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 | 9.5% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.2% | 18.5% | 6.5% | better 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 | 6.6% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.2% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 10.8% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.6% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.1% | 63.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.0% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.4% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.32 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.76 | 2.33 | 1.80 | better |
‡ 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.
53.5% 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 236 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 81 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 53.5%CMS range 47.3–59.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.4–14.4 | 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 | 63.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.7% | 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 | 38.3% | 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 | 98.9% | 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 | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 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 | 2.1% | 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 | 6.2%CMS range 3.6–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.68 | 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 144 beds and averages 130.6 residents a day — about 91% occupied, or roughly 13 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 4.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 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 4.43 hrs/resident/day on weekends vs 4.67 on weekdays — 5% thinner on weekends. RN hours go from 0.61 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2024-04-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, interview, and record review, the facility failed to ensure one of four sampled residents was free from physical abuse by an agency Certified Nurse Aide (CNA). Review of a video, showed on the morning of 3/17/24, agency CNA A stood at Resident #1's bedside. He/She had one hand behind the resident's neck and with the other, pulled on the resident's leg towards a sitting position. The resident hit the CNA. With his/her right hand, CNA A punched the resident in the neck. He/She then loudly said, Stop. Why did you do that? The census was 136. On 04/12/24 9:49 A.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 03/17/24. On 03/17/24, the administrator was notified of the incident and an investigation was started. CNA A was sent home and placed on the do not return list. Facility staff received education on Freedom from Abuse and Neglect. The IJ was corrected on 3/18/24. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy, dated 10/2022, showed 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.
- Actual harm · Gcited before2024-02-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents, who had a change in condition, was monitored and assessed, according to professional standards, by a licensed nurse throughout the night. The resident was sent to the hospital the next morning, intubated (tube inserted through the mouth and into the lungs so the person can be placed on a ventilator to assist with breathing) in the emergency room (ER) for respiratory failure (a condition in which the blood does not have enough oxygen), and admitted to the intensive care unit (ICU) for respiratory failure, atrial fibrillation (an irregular and rapid heartbeat) and septic shock (the most severe complication of sepsis and carries a high mortality) (Resident #2). The census was 129. Review of the facility's Acute Change of Condition policy, dated 8/2019, showed: -It is the policy of this facility to promptly identify, evaluate, and address a resident's change in condition, and to: -Immediately notify 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.
- Potential for harm · E2025-01-28 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when staff failed to serve a requested alternate meal and told the resident to wait until the next meal (Resident #91), failed to serve a resident timely after the tablemates were served (Resident #109). The facility staff also failed to answer a resident after asking staff several times (Resident #44) and staff entered the resident rooms without knocking on the door (Residents #67, #102 and #110). The sample was 26. The census was 132. Review of the facility's Resident Rights: Accommodation of Needs and Preferences and Homelike Environment policy, dated August 2019, showed: -It is the policy of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. Residents…
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 · E2025-01-28 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
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 each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for eight of 10 sampled Certified Nursing Assistants (CNA) and Certified Medication Technicians (CMT). The census was 132. Review of the facility's Compliance Education and Training Policy, dated 7/1/2019, showed: -Purpose: The purpose of this policy is to standardize the requirements for initial orientation, ongoing training, focus training, and corrective training in order to educate employees and non- employees on compliance with laws regulations and facility policies and procedures, and to promote accountability; -Policy statement: The facility requires that all employees receive training on compliance with laws, regulations, facility policies and procedures, and standards of conduct. Non-employees including board members, vendor representatives, contractors, students, and volunteers who regularly work at the facility or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-28 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for ten out of ten narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 132. Review of the facility's Controlled Substances policy, original date 8/19, showed: It is the policy of Friendship Village to ensure compliance with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. -Only authorized licensed nurses that are permanent employees of Friendship Village or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. *No agency nurse is allowed to carry narcotic keys or administer narcotics to any resident. -Controlled substances must be counted upon delivery. The nurse receiving the order must count the controlled substances together with Shift Supervisor. Both individuals must sign 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 · E2025-01-28 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors. Staff failed to administer a medication for one resident with a diagnosis of obstructive uropathy (occurs when urine flow is blocked, causing urine to build up in the kidneys) who required the medication to empty their bladder and increase urination (Resident #29). Staff failed to administer several doses of a medication used to treat anxiety for one resident (Resident #110). Staff also administered an expired medication, used to treat Parkinson's disease (an age-related degenerative brain condition) for over a week. The medication was ordered to be given twice a day. The bottle showed the medication expired October 2024 (Resident #227). These failures put residents at risk for significant medication errors that went undetected and unreported to the physician, resulting in potential for compilations related to missed doses and administering expired medications. The sample…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected three of four sampled residents, whose care plan did not identify self-harm (Resident #96) sexual behaviors (Resident #109) and hospice services (Resident #29). The sample was 26. The census was 132. Review of the facility's Care Planning policy, dated August 2019, showed: -Policy: It is the policy of the facility for the Care Planning/Interdisciplinary Team to develop and to implement a person-centered comprehensive care plan for each resident to meet the resident's preferences and goals, and to address medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment; -A comprehensive care plan for each resident is developed within seven days of completion of the comprehensive resident assessment; -The resident's care plan must be reviewed after each Omnibus Budget Reconciliation Act (OBRA) assessment, except…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on observation, interview and record review, the facility failed to ensure residents receive care consistent with professional standards. Staff failed to complete a documented assessment and documented notifications to the physician and family regarding a resident's knee wound. Staff also failed to obtain a physician's order for a dressing to the resident's right knee (Resident #110). The sample size was 26. The census was 132. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 8/2019, showed: -Policy: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure injuries; To implement preventative measures; and to provide appropriate treatment modalities for wounds according to the industry standards of care. -Procedure: Monitoring of skin integrity. Skin will be observed daily with care by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. Weekly skin audits on the bath or shower day will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, four errors occurred, resulting in a 13.33% error rate (Residents #60 and #98). Staff did not measure a medication in powder form on a level surface, provided a bottle of nasal spray to a resident and did not stop the resident at the ordered doses, crushed a medication that should not have been crushed and left crushed medications unattended on the medication cart. The census was 132. Review of the facility's Medication Administration, policy dated 8/19, showed: -Purpose: To clearly define Drug Administration policies in accordance with all applicable laws and standards of practice. Review of the facility's Crushing Medications policy, dated 8/19, showed: -Purpose: To enable the resident who has difficulty swallowing to take medications orally. Review of the facility's Medications Not to be Crushed list, revised 7/19, showed: -Ezetimibe (to treat high cholesterol) tablet not be crushed due to manufacturers recommendation. 1.…
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 · D2025-01-28 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 provided therapeutic diets as recommended by the physician and the Registered Dietician (RD), for one resident with weight loss (Resident #109). The facility failed to provide the resident's fortified chocolate milk for two observed meals. The facility also failed to provide the extra items listed on the meal ticket. The sample was 26. The census was 132. Review of Resident #109's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses wheelchair for mobility; -Weight: 163 pounds (lbs); -Supervision or touching assistance for eating (Helper provides cues or touching/steadying assistance as resident completes activity); -Diagnoses include acid reflux, diabetes, malnutrition, dementia and depression. Review of the resident's current care plan, showed: -Problem: Resident has potential for cognitive impairment; -Interventions: None listed -Goal: Resident's nutritional status will remain stable as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff failed use proper hand hygiene while providing care for two of three sampled residents observed for incontinence care (Residents #110 and #44). The census was 132. Review of the facility's Hand Hygiene policy, dated 8/19, showed: -Purpose: hand hygiene is required in order to reduce the spread of potentially dangerous infectious agents and to reduce the risk of colonization or infection for health care workers that could be potentially acquired from the resident; -Policy Statement: It is the policy of this facility that hand hygiene will be provided consistent with best practices. Hand hygiene (hand washing and/or alcohol based hand rub (ABHR) includes the use of ABHR instead of soap and water in all clinical situations except when the hands are visibly soiled (blood or bodily fluids) or after caring for a resident with known or suspected Clostridium…
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 · F2023-09-28 · 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 observations, interviews, facility document review, and facility policy review, the facility failed to maintain 3 of 3 ice and water dispensers in the first, second, and third-floor beverage areas used for residents and staff. This had the potential to affect all 131 residents who resided in the facility at the time of the survey. Findings included: Review of the Nugget Ice Machines Installation, Operation and Maintenance Manual, revised in December 2017, indicated, If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing. Sanitizing procedure indicated Note: Sanitizing must be performed on adjacent surface areas not contacted by the water distribution system. Step 5 Remove the top cover to the ice chute and pour the sanitizer/water solution into the evaporator. Step 6 Replace the ice chute cover and allow the ice machine to stand for 30 minutes. Review of the facility's…
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 12 citations
- Potential for harm · D2023-09-28 · 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
Based on interview, record review, and facility policy review, the facility failed to ensure medications were reconciled to ensure a safe discharge for 1 (Resident #229) of 3 sampled residents reviewed for discharge requirements. Findings included: Review of a facility policy titled, Discharge Summary, dated August 2019, indicated Objective of the Discharge Summary policy To ensure the facility communicates necessary information to the resident, continuing care provider and other authorized persons at the time of an anticipated discharge. The policy specified, When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). A review of Resident #229's Profile Face Sheet indicated the facility admitted the resident on 12/30/2021 with diagnoses that included nondisplaced hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke), fracture of left…
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 before2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plans that addressed resident care needs for 2 (Resident #97 and Resident #229) of 27 sampled residents. Specifically, Resident #97 did not have a care plan to address their diagnosis of diabetes mellitus and use of insulin and Resident #229 did not have a care plan to address the use of an indwelling urinary catheter. Findings included: Review of facility policy titled, Comprehensive Care Plan, dated August of 2019, revealed, The policy of this facility is that each resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals and to address the resident's medical, physical, mental, and psychosocial needs. 1. A review of Resident #97's Profile Face Sheet indicated the facility admitted Resident #97 on 01/28/2022 with a diagnosis that include type 2 diabetes mellitus. A review of Resident #97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/04/2023, revealed Resident #97 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADLs) necessary to maintain good grooming and personal hygiene for 1 (Resident #35) of 2 sampled residents reviewed for assistance with ADL care. Specifically, Resident #35 had fingernails that were long and dirty, and the resident did not receive showers according to their plan of care. Findings included: Review of a facility policy titled, Nail Care, dated August 2019, revealed Purpose - To promote cleanliness, safety and a neat appearance. - To observe skin condition on fingers and toes. Review of a facility policy titled, AM [morning] Care, dated August 2019, revealed It is the policy of this facility to provide the necessary morning care and services based upon the comprehensive assessment of a resident and consistent with the resident's needs and choices, or order to maintain or improve resident's ability to carry out the activities of daily living. The policy indicated, Purpose - To prepare…
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 before2023-09-28 · 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
Based on interviews, record review, and facility document and policy review, the facility failed to investigate and determine causative factors of falls to help prevent and/or reduce the risk of further falls for 2 (Residents #429 and Resident #100) of 6 sampled residents reviewed for accidents. Findings included: A review of the facility's policy titled, Strategies for Managing Falls, dated August 2019, revealed, It is the policy of this facility to evaluate each resident immediately after a fall. Further review of the policy indicated, 7. Notify the interdisciplinary team and perform team huddle to investigate and discuss fall and possible causes. 1. Review of Resident #429's Profile Face Sheet revealed the facility most recently readmitted the resident on 03/19/2023 with diagnoses that included dementia without behavioral disturbance, Alzheimer's disease, anxiety disorder, and major depressive disorder. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2023, revealed Resident #429 had a Brief Interview for Mental Status (BIMS) score…
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 · D2023-09-28 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure pain medication was timely administered for 1 Resident #32) of 1 sampled resident reviewed for pain management. Findings included: The facility's policy titled, Pain Management, dated August of 2019, revealed, It is the policy of the facility that all residents will be assessed for presence, absence or history of pain on admission, quarterly, with a significant change in status and with the new onset of pain or discomfort, in order to plan a plan a pain management program for an acceptable level of resident comfort whenever possible. Review of Resident #32's Profile Face Sheet indicated the facility most recently readmitted the resident on 01/22/2021 with diagnoses that included osteoarthritis, unspecified fractures of the thoracic vertebrae, and chronic pain. Review of Resident #32's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident 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 · Dcited before2023-09-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure hand hygiene was performed during wound care for 1 (Resident #52) of 2 sampled residents reviewed for pressure ulcers/injuries. Findings included: Review of a facility policy titled, Hand Hygiene Policy, dated August 2022, indicated, Perform hand hygiene in the following situations. a. When coming on duty and going off duty. b. Before and after touching a resident or their environment. c. Before putting on gloves. d. After removing gloves. e. After removing personal protective equipment (PPE) f. When moving from a contaminated body site to a clean body site during resident care. Review of a Profile Face Sheet indicated the facility admitted Resident #52 on 03/17/2022 with diagnoses that included congestive heart failure, chronic kidney disease, and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2023, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated 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.
- Potential for harm · E2019-08-28 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed physician's orders and the facility policy regarding elevated blood sugars. The facility identified 15 residents with orders for routine blood sugar checks (accu-checks). Of those 15, two had elevated blood sugars that exceeded the physician's parameters and the facility policy and problems were found with both (Residents #56 and #62). In addition, the facility failed to ensure staff completed the 72 hour fall follow-up neurological and vital sign form after two residents had falls with suspected head injuries (Residents #23 and #59). The census was 108 with 85 in certified beds. Review of the facility policy on hyperglycemia, dated 8/19, showed: Purpose: To prevent complications with hyperglycemia; Definition: -Hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can't use insulin properly; Procedure: -Glycemic…
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 · E2019-08-28 · tag F0700 — patternTry 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 staff thoroughly assessed and reassessed one resident's side rails/bed rails after staff found the resident's legs caught in the bed rail, causing a skin tear (Resident #52). In addition, seven of 18 additional sampled residents were observed with bed rails in use and problems were identified with all seven of those residents (Residents #25, #24, #35, #70, #275, #14 and #23). The census was 108 with 85 in certified beds. Review of the facility's Side Rails/Bed Rails Policy, dated August 2019, showed: -Preface: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenance and individual bed rail evaluations. The facility will also ensure individual resident bed rail evaluations are performed on a regular basis. Individual bed rail evaluations will include data…
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 before2019-08-28 · 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 adequately assess residents for the use of bed rails/side rails and failed to implement appropriate interventions to prevent injuries for two of 18 sampled residents after sustaining injuries during the use of bed rails/side rails (Resident #52 and #35). The census was 108 with 85 in certified beds. 1. Review of Resident #52's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/19, showed: -Moderate cognitive impairment; -Extensive assistance of one person required for bed mobility and transfers; -Diagnoses included hip fracture and Parkinson's disease; -Two falls without injury and one fall with injury since admission; -Bed rails not used. Review of the resident's medical record, showed: -An order, dated 1/14/19, for enabler bars times two to assist in repositioning; -Bed Rail/Assist Bar Evaluations, dated 4/22/19 and 8/1/19, marked as follows: -Type of bed rail/assist bar:…
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 before2019-08-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 26 opportunities observed, there were three errors resulting in an 11.54% medication error rate (Resident #176). The census was 108 with 85 in certified beds. Review of the facility's policy on Medication Administration, dated 8/2019, showed: -Purpose: To clearly define drug administration policies in accordance with all applicable laws and standards of practice; -Policy: #7. All personnel administering medications will ensure that the medication is given: To the right person. The right medication - verified with physician order. The right dose - verified with physician order and standards of practice. The right time and the right route. Review of Resident #176's physician's order sheet (POS), dated August 2019, showed: -Omeprazole (medication used to treat heartburn) 20 milligram (mg) one capsule by mouth every morning at 7:00 A.M.; -Calcium (mineral) 500 mg (1,250 mg) by mouth every morning; -Promod Liquid Protein (protein supplement) 30…
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 before2019-08-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during incontinence care for two of two observations (Residents #17 and #11). The census was 108 with 85 in certified beds. Review of the facility's policy on Standard precautions, undated, showed the following: -Purpose: It is the purpose of the facility to apply Standard Precautions to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases and apply to the care. Staff will be adequately trained in the various aspects of Standard Precautions to ensure appropriate decision making in various clinical situations; -Procedure: Gloves: #5. Change gloves as necessary, during care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). #6. Do not reuse gloves. Remove gloves promptly after use, before touching non-contaminated surfaces and before going to another…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2019-08-28 · tag F0623 — patternProvide 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 issue written Emergency Transfer notices to residents and/or representatives as soon as practicable when residents were temporarily transferred on an emergency basis to an acute care facility, and their return to the facility was expected (Residents #76 and #275). The census was 108 with 85 in certified beds. Review of the facility's Bed Hold Statement and Notice of Emergency Transfers, showed: -Upon admission to the facility and again if the resident is transferred to an acute care hospital, the resident (if able) or the responsible party is informed of the policy on bed holds. When a resident is transferred to the hospital, the resident (if able) or the responsible party will be contacted regarding their preference for bed hold. The responsible party or resident has the option of having the resident' bed held. Written verification of the bed hold decision will be mailed to the resident or responsible party. The bed hold rate will be the resident's…
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
$14,433 in federal fines across 1 penalty.
- $14,433 — penalty dated 2024-04-15
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FV SERVICES, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/17/2025 |
| BOLSTAD, CINDY | Individual | CORPORATE DIRECTOR | — | since 06/24/2020 |
| KLINGER, JEFFREY | Individual | CORPORATE DIRECTOR | — | since 07/01/2011 |
| UTLEY, KEITH | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/01/2017 |
| WALSH, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 08/09/2016 |
| ZIMMERMANN, JOAN | Individual | CORPORATE DIRECTOR | — | since 06/30/2025 |
| WRIGHT, JOSHUA | Individual | CORPORATE OFFICER | — | since 07/01/2024 |
| BROSCH, SIRISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/04/2025 |
| LIVERAR, BOBBIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2025 |
CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $977K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 265136. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-28, 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.