Sunterra Springs Springfield
4935 S National Ave, Springfield, MO 65810 · For profit - Limited Liability company · 38 certified beds · (417) 720-8050 Medicare only — no Medicaid
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 (F0602), cited Sep 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $36,696 in federal fines (most recent 2023-10-10)
- its facility-reported quality-measure score sits well above its independent inspection score
- nursing-staff turnover (66%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
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 | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 54.4% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.4% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.9% | 13.7% | 12.0% | better |
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.
66.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 558 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.6% 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 186 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 1.00 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 66.8%CMS range 62.8–70.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.8–13.4 | 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 | 72.6% | 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 | 75.3% | 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 | 67.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 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 | 96.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 97.5% | 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 | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 5.3–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 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 38 beds and averages 37.4 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 4.23 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.33 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 66% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Fcited before2025-06-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in a manner to prevent possible contamination when staff failed to wash hands and change gloves appropriately during food prep and service, and when staff failed to cover food on a rack. The facility was census was 37. 1. Review of the facility's policy titled, Maintaining a Sanitary Tray Line, revised April 2025, showed the following: -This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness; -During tray assembly, staff shall use utensils such as tongs and serving spoons to handle food as much as possible; -Wear gloves when handling food items, particularly when direct contact between the hands and food occurs or when handling ready-to-eat foods such as salads, fruits, sandwiches, bread; -Use gloves that fit properly; -Wash hands before and after wearing or changing gloves; -Change gloves when activities are changed, or when the type of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-02 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the facility implement their abuse and neglect policies when staff failed to complete a criminal background checks (CBCs) for one of ten sampled employees prior to their hire/start date in a facility with a census of 37. Review of the facility's policy, Abuse, Neglect and Exploitation, revised April 2025, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property; -Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property; -Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants; -Screenings may be conducted by the facility itself, third-party agency, or academic institution; -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 · Ecited before2025-06-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program when staff failed to follow Enhanced Barrier Precautions (EBP-infection control measures used to reduce transmission of resistant organisms) while providing wound care for three residents (Resident #2, #197, and #14) and when staff failed to place a protective barrier beneath supplies in two resident rooms (Resident #197 and #14). The facility census was 37. Review of a facility policy titled Enhanced Barrier Precautions, dated April 2025, showed the following: -It is the facility policy to implement EBP for the transmission of multi-drug resistant organisms (MDRO); -All staff receive training on EBP upon hire and at least annually, and are expected to comply with all designated precautions; -An order for EBP will be obtained for residents with wounds, medical devices, and infection with an MDRO; -Personal protective equipment (PPE) for EBP is only necessary when performing…
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 · E2025-06-02 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a sanitary environment when staff failed to keep non-food contact surfaces of the floor, stove, warmer, and can opener clean and well maintained in the kitchen. The facility census was 37. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -The physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled, Sanitation Inspection, revised April 2025, showed the following: -It is the policy of the facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations; -All food service areas shall be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. 1. Observations on 05/27/25, at 11:49 A.M., on 05/28/25, at 8:50 A.M., and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-02 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 each resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record when staff did not update the care plan for one resident (Resident #36) and when the physician did not date the code status form for one resident (Resident #140) out of a sample of two residents. The facility census was 37. Review of the facility's policy titled, Communication of Code Status, revised [DATE], showed the following: -It was the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -When an order is written pertaining to a resident's presence or absence of an advance directive, the directions will be clearly document 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.
- Potential for harm · D2025-06-02 · 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 observation, record review, and interview, the facility failed to ensure care was provided in accordance with standards of practice when staff failed to consistently document full assessments of a wound, failed to document physician notification of wound deterioration and resident refusals of treatment, failed to maintain a current and accurate wound care plan, and failed to fully document regarding new wounds and failed to document physician notification of new wounds for one resident (Resident #37). The facility also failed to failed to monitor blood glucose level four times daily per physician's order for one resident (Resident # 197). The facility census was 37. 1. Review of the facility's policy titled, Documentation of Wound Treatments, revised April 2025, showed the following: -The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment; -Wound assessments are documented upon admission, weekly,…
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 · D2025-06-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain ensure catheter (a tube inserted into the bladder, allowing your urine to drain freely) use per standards of practice when staff failed to obtain a complete order indicating the size of the catheter used and a corresponding diagnosis and when staff failed to document monitoring and care of the catheter as ordered for one resident (Resident #14) out of a sample size of 13 residents. The facility census was 37. Review of a facility policy titled, Appropriate Use of Indwelling Catheters, dated May 2025, showed the following: -An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary; -It is the policy of the facility to ensure a resident admitted with a urinary catheter will be assessed for removal of the catheter unless the resident's clinical condition indicates catheterization is necessary; -The use of an indwelling catheter will be in accordance with physician orders and include the diagnosis or clinical condition making the use of a catheter…
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 · D2025-06-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for one resident (Resident #142) out of a sample of four residents. The facility census was 37. Review of the facility's policy titled Oxygen Administration, revised April 2025, showed the following: -Oxygen is administered to residents who need it consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; -Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control; -Personnel authorized to initiate oxygen therapy include physicians, registered nurses, licensed practical nurses, and respiratory therapists. 1. Review of Resident #142's face sheet (a brief resident profile) showed the following: -admission date of 05/20/25; -Diagnoses…
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 · D2025-06-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure pain services provided per standards of practice when staff failed to document providing appropriate pain medication to address pain in a timely manner for one resident (Resident #93) admitted from the hospital after knee replacement surgery. The facility census was 37. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders; -The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission; -The orders should provide information…
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 · D2025-06-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide pharmacy services per standards of practice when staff failed to administer medications after receipt for one newly admitted resident (Resident #93) and when staff failed to properly document the removal of Fentanyl patches (a narcotic pain medication) for one resident (Resident # 197). The facility census was 37 residents. 1. Review of the facility policy admission Orders. revised 04/2025, showed the following: -A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs; -The written and/or verbal orders should include at a minimum dietary, medication orders if indicated, and routine care orders. Review of Resident #93's face sheet (admission information at a glance) showed the following: -admission date of 05/25/25;…
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 17 citations
- Potential for harm · Dcited before2025-06-02 · 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, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made 4 errors out of 45 opportunities resulting in an 8.8% error rate affecting one resident (Resident #142). The facility had a census of 37. Review of a facility policy titled Medication Administration, dated April 2025, showed the following: -Medications are administered as ordered by the physician and in accordance with professional standards of practice; -Obtain and record vital signs per physician orders; -Hold medication for those vital signs outside the physician's prescribed parameters; -Ensure the six rights of medication administration are followed which are right resident, right drug, right dosage, right route, right time, and right documentation; -Administer within sixty minutes prior to or after scheduled time unless otherwise ordered by a physician; -Sign Medication Administration Record (MAR) after administered and record vital signs on the MAR. 1. Review of Resident #142's face sheet (document that gives a resident's information at 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 · Dcited before2025-03-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when the facility staff failed to document a full assessment of wounds upon admission, failed to obtain physician's orders for treatment and interventions of wounds, and failed to update the care plan regarding skin breakdown intervention changes for one resident (Resident #1) out of 7 sampled residents. The facility census was 37. Review of the facility's policy titled, Skin Assessment, dated 07/21, showed the following information: -A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse (RN) upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury; -The following should be documented: date and time of the assessment, staff members name and position title,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported timely when staff failed to report an allegation of abuse involving one resident (Resident #3) to the state survey agency (Department of Health and Senior Services (DHSS)) within the required two hour time frame. The facility census was 36. Review of the facility's policy Abuse, Neglect and Exploitation, revised 06/2023, which showed the following: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document a full assessment of wounds upon admission; failed to document on-going full assessments of wound to assist with monitoring and possible decline of wound; failed to obtain physician's orders for treatment and failed to follow ordered treatments of pressure ulcers; and failed to care plan and update care plans regarding actual skin breakdown and intervention changes for two residents (Residents #1 and #2) of six sampled residents. The facility census was 36. Review of the facility policy Skin Assessment, revised 7/2024, showed the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter; -The assessment may also be performed after a change of condition or after any newly identified pressure injury; -Procedure included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers, when staff stacked dishes while still wet, and when staff failed to ensure the dishwasher rinsed the dishes at the recommended temperature. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 37 residents. 1. Review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Observations of the kitchen on 11/06/23, at 8:45 A.M., showed the following: -An opened bag of parmesan cheese in the walk in refrigerator with a binder clip on it. The bag was not sealed and was partially opened to the air; -A large steel container in the walk in freezer with aluminum foil covering the top labeled chicken rice soup. The aluminum foil had several holes in it leaving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-09 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's choice of code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) was accurate and matched throughout the record when three residents' (Resident #135, #133, & #132) code statuses (do not resuscitate (DNR - the resident did not wish to received cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions often combined with artificial ventilation) or CPR (full code status)) failed matched through the medical record. A sample of 13 residents was selected for review out of a facility census of 37. Review of the facility policy titled Communication of Code Status. dated June 2023, showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; -In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -The facility will follow policy regarding 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 · D2023-11-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure the interdisciplinary team approved all self-administration of medication, obtained orders for the self-administration of medication, and care planned the self-administration for two residents (Resident #182 and #87) with a medication at bedside. The facility census was 37. Review of the facility policy titled Resident Self-Administration of Medication, dated June 2023, showed the following information: -It is the policy of this facility to support each resident's right to self-administer medication; -A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; - Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team; -Resident's preference will be documented on the appropriate form and placed in the medical record; -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary…
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 · D2023-11-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY \\ Based on record review and interview, the facility failed to complete a discharge Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident #6) in a timely manner. The facility census was 37. Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #6's face sheet showed an admission date of 06/30/23. Review of the resident's electronic medical record (EMR), census tab, showed the following: -admission date of 06/08/23; -discharge date of 06/30/23 with return not anticipated. Review of the resident's EMR progress notes showed the following: -On 06/29/23, at 5:00 P.M., Social Services documented the resident planned to discharge home with family and any needed services and/or equipment were in place. Family planned to pick up the resident at 4:00 P.M. on 06/30/23; -On 06/30/23, at 8:39 A.M., nursing staff documented the resident plan was to discharge this date. Review of 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.
- Potential for harm · Dcited before2023-11-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 27 opportunities resulting in an error rate of 7.4% when staff failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to…
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 · D2023-11-09 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 resident were free of significan medication erros when failed to administer the correct insulin type for one resident (Resident #132); failed to administer the correct insulin dosage for one resident (Resident #134); and failed to follow manufacturer guidelines and did not prime the insulin pen prior to insulin administration for two residents (Resident #132 and #134). The facility census was 37. Review of the facility policy titled Medication Administration, dated June 2023, showed the following information: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the Medication Administration Record (MAR) to identify the medication to be administered; -Compare medication card with MAR to verify the resident name, 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.
- Potential for harm · D2023-11-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed maintain all residents records per standard of practice when the facility failed to document administration and placement of a Fentanyl patch in the Medication Administration Record (MAR) for one resident (Resident #183). The facility census was 37. 1. Review of showed the facility did not provide a policy regarding documentation of medication administration. Review of Resident #183's face sheet (a brief profile) showed the following: -admission date of 10/27/23; -Diagnoses included of spinal stenosis of sacral and sacrococcygeal region (narrowing of the spine causing compression of the bottom of the spine near the tailbone) and spondylosis without myelopathy or radiculopathy of lumber region (osteoarthritic changes affecting the triad of joints forming the spinal columns). Review of the resident's care plan, revised 10/28/23, showed the following: -The resident has chronic lower back pain; -Staff will monitor the resident for interruption of activities of daily living (ADL - dressing, grooming, bathing, eating, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain an effective infection prevention program when staff failed to ensure two residents (Residents #5 and #82) and three staff members were tested for tuberculosis (a type of bacterial infection mainly affecting the lungs and is a communicable disease) per standards of practice and current guidance. A sample of 13 residents was selected for review out of a facility census of 37. 1. Review showed the facility did not provide a policy regarding TB testing or monitoring of residents. Review of the Centers for Disease Control (CDC) guidance for resident TB testing showed the following: -Skin tests should be administered to all new residents as soon as their residency begins unless they have documentation of a previous positive reaction; -A two-step procedure is advisable for the initial testing of residents in order to establish a reliable baseline; -Each skin test should be administered and read by appropriately trained personnel and recorded (in millimeters (mm) induration) in the person's medical record; -A record of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-12 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 F602 Based on observation, interview, and record review, the facility the facility failed to keep all residents free from misappropriation of property when one staff (Registered Nurse (RN) A) took medications belonging to one resident (Resident #1). The census was 35. Please refer to event OSDG11 for full survey text. The surveyor interviewed seven residents, 12 staff, and one family members,and reviewed five medical records, including the record of [NAME] Revie. The facility conducted proper pre-employment screening of the alleged perpetrator (AP), [NAME], prior to hiring him. This screening included, application for employment, Missouri Certified Nurse Assistant Registry check, the Family Care Safety Registry Check, and an exclusions screening. In addition, the facility provided Resident Rights, and Abuse and Neglect training. The allegation of misappropriation was made to DHSS on 8/23/2023 and F602 was issued. (Exhibit A, page 1-4 and 6 ) Please see the information below regarding the EDL referral. 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 · D2023-09-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide all resident with care in accordance with professional standards when staff failed to follow physician orders and did not administer a medication as ordered for four days for one resident (Resident #1). The facility census was 35. Review of the facility policy, Medication Administration, revised 06/2023, showed the following information: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician, in accordance with the professional standards of practice, and in a manner to prevent contamination or infection; -Keep medication cart clean, organized, and stocked with adequate supplies; -Review Medication Record Administration (MAR) to identify medication to be administered; -Administer medication as ordered; -Sign MAR after administered; -Correct any discrepancies and report to nurse manager. 1. Review of Resident #1's face sheet (a document that gives a 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.
- Potential for harm · E2021-07-29 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to have practices in place to ensure food served to residents was palatable, attractive, and at an appetizing temperature. The facility had a census of 38. 1. During an interview on 7/27/2021, at 9:50 A.M., Resident #266 said he/she received cold green beans on the first evening meal when he/she came to the facility. During the resident council meeting on 7/27/2021, at 2:00 P.M., Resident #220 said the following: -Breakfast is always cold on 100 hall; -The biscuits and gravy are so cold, the grease sticks to the roof of his/her mouth. Observation on 7/28/2021, at 12:25 P.M., of a sampled food tray pulled from the 200 hall cart showed the following: -The chicken sandwich and roasted potatoes were both cold and unappetizing. During an interview on 7/28/2021, at 2:50 P.M., Resident #169 said his/her meal tray is served in his/her room and the food is always cold. During an interview on 7/29/2021, at 8:38 A.M., Certified Nursing Assistant (CNA) F said sometimes a resident will complain of cold food. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-07-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice when all staff did not properly wear face coverings in the rooms of residents and common areas of the facility during a Coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic. Additionally, staff failed to properly clean and disinfect glucometers (machine used to test blood glucose levels) between uses for four residents (Residents #1, #121, #123 and #223). The facility census was 38. 1. Record review of the updated guidance for healthcare workers from Centers for Disease Control and Prevention (CDC) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/23/2021, showed the following: -Health Care Providers (HCP) should wear well-fitting source…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-29 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 accommodate one resident's (Resident #267) intolerances and food preferences. The facility census was 38. Record review of the facility's policy titled, Resident Food Preferences, dated 11/17/2017, showed the following information: -Upon the resident's admission, or within twenty-four hours after his/her admission, the dietician or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident; -The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions; -The dietician will visit residents periodically to determine if revisions are needed regarding food preferences; -The nursing staff will inform the kitchen about resident requests; -The Food Services Department will offer a limited number of food…
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
$36,696 in federal fines across 8 penalties. 1 Medicare payment denial on record.
- $4,587 — penalty dated 2023-10-10
- $4,587 — penalty dated 2023-10-02
- $4,587 — penalty dated 2023-09-25
- $4,587 — penalty dated 2023-09-18
- $4,587 — penalty dated 2023-09-11
- $4,587 — penalty dated 2023-09-05
- $4,587 — penalty dated 2023-08-28
- $4,587 — penalty dated 2023-08-21
- Medicare payment denial — starting 2025-09-02 for 4 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SUNTERRA SPRINGS — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 3 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| RMC ENTERPRISES LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/01/2025 |
| BALL VENTURES LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2025 |
| BV OPERATIONS LLC. | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2025 |
| BV PAC HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/01/2025 |
| DLB LEGACY LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/01/2025 |
| RMCE OPERATIONS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 03/15/2026 |
| BALL, ALLEN | Individual | INDIRECT OWNERSHIP INTEREST | since 04/01/2025 |
| BALL, CONNIE | Individual | INDIRECT OWNERSHIP INTEREST | since 04/01/2025 |
| BANGERTE, NATHAN | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | since 03/28/2025 |
| BANGERTER, DEE | Individual | INDIRECT OWNERSHIP INTEREST | since 04/01/2025 |
| BANGERTER, EDWARD | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| BANGERTER, JOHNATHAN | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| SHRADER, RICHARD | Individual | INDIRECT OWNERSHIP INTEREST | since 03/28/2025 |
| DARBY, MEGAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| GATHERUM, JASON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| NEVES, COURTNEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| SNOWBALL, KELLY | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2025 |
| KELLOGG, DEATRICE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2025 |
| RICHARDSON, EULA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/20/2024 |
| STEVENS, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| ROCKY MOUNTAIN CARE LLC | Organization | ADP OF THE SNF | since 07/30/2025 |
CMS files one row per role, so the 30 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Missouri Medicaid page for homes that do.
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 265871. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-02, 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 →
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