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Sunset Health Care Center

400 West Park Avenue, Union, MO 63084 · For profit - Corporation · 120 certified beds · (636) 583-2252 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Apr 2025Resident-funds citations (F0569, F0570)1 immediate-jeopardy citation$8,281 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0569, F0570)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-05-30)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
305 N Highway 47 · (636) 583-1595 · Call to confirm hours
Pharmacy
707 US Highway 50 W · (636) 583-2646 · Call to confirm hours
Grocery
10 Locust Ave · (636) 583-2181 · Call to confirm hours
Park
500 W Park Ave · (636) 583-8471 · Typically dawn to dusk
Place of worship
408 W Main St · (636) 583-1040

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 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.5%18.1%15.4%better
Long-stay residents who lose too much weight2.7%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection0.9%2.3%2.0%better
Long-stay residents with depressive symptoms30.0%18.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.4%4.1%3.3%typical
Long-stay residents whose ability to walk worsened6.7%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.1%25.6%18.9%typical
Long-stay residents given the seasonal flu vaccine90.9%90.9%95.3%typical
Long-stay residents with pressure ulcers2.0%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control18.5%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table61.3%23.5%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine30.6%63.5%79.4%worse
Short-stay residents rehospitalized after admission20.0%26.0%22.6%better
Short-stay residents with an outpatient ER visit10.0%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days3.152.111.67worse
Long-stay outpatient ER visits per 1,000 resident days2.172.331.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
30.0%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 30.0% 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 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 37.9–68.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.5–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge30.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge13.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge26.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified84.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.3%CMS range 4.8–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.24
RN hours/ resident / day
0.70
LPN hours/ resident / day
1.97
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.14
RN hoursweekends
26.7%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 116.7 residents a day — about 97% occupied, or roughly 3 beds 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.66 hrs/resident/day on weekends vs 3.01 on weekdays — 12% thinner on weekends. RN hours go from 0.28 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-05-30)
11
at the previous standard inspection (2024-01-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-05-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to propel four (Resident #3, #7, #24, and #111) out of six residents in a wheelchair in a manner to ensure resident safety. The facility census was 114. 1. Review of the facility's policies showed staff did not provide a policy for wheelchair safety. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/14/25, showed staff assessed the resident as: -Cognitively impaired; -Required partial to moderate assistance for ambulation greater than 50 feet; -No wheelchair. Observation on 05/28/25 at 9:11 A.M., showed Licensed Practical Nurse (LPN) E propelled from the 200 secured unit to the 100 hallway to the scale, weigh the resident, and return the resident to the 200 hallway. The wheelchair did not have leg pedals in place and the bottom of the resident's feet slid on the floor. During an interview on 05/28/25 at 9:22 A.M., LPN E said he/she borrowed a wheelchair to take the resident to get…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-30 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 114. 1. Review of the resident's trust fund account for July 2024 through April 2025, showed an average monthly balance of $199,493.16, which required a surety bond of $300,000.00. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $250,000.00. During an interview on 05/28/25 at 1:42 P.M., the business office manager (BOM) said he/she is responsible for resident funds and ensuring the bond is sufficient. He/She said he/she is aware their bond needs to be increased. He/She said they have had several changes that have made their monthly balance increase, and he/she noticed it was getting close to the bond amount. During an interview on 05/29/25 at 12:57 P.M., the administrator said the BOM is responsible for resident funds and ensuring the surety bond is sufficient. He/She said…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff failed to complete hand hygiene between glove changes during wound care for three residents (Resident #4, #28,and #216) of three sampled residents with wounds and when staff failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for three employees (Certified nurse aide (CNA) N, Maintenance assistant, and Housekeeper O) out of ten employee files reviewed. The facility census was 114. 1. Review of the facility's Standard Precautions policy, dated October 2022, showed the policy did not contain direction or guidance for hand hygiene between glove changes. Review of the facility's Hand Hygiene policy, dated April 2022, showed staff are directed to perform hand hygiene before and after…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to keep Resident #2 from striking Resident #1 twice to the chest. The facility census was 114. The administrator was notified on 3/27/25 of past Non-Compliance, which occurred on 3/22/25 when Resident #1 struck Resident #2 to the chest twice. Staff immediately separated the residents, assessed the residents, notified the resident's physician, moved Resident #1 to a different hallway, put Resident #2 on one on one, and in-serviced nursing staff on abuse and neglect. Staff corrected the deficient practice on 3/25/25. 1. Review of the facility's Abuse prevention policy, dated 10/21/22, showed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-04-07 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff failed to have an appropriate location to transfer one resident (Resident #2) to when he/she was ready to discharge from the hospital. The facility census was 114. 1. Review of the facility's Discharge and Transfer - Involuntary Policy, reviewed 10/07/2021, showed transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant to not. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria are met. The facility will provide sufficient orientation to residents to ensure a safe and orderly transfer or discharge from the facility including an opportunity to to participate in the decision of where to transfer. 2. Review of Resident #1's facesheet, dated 4/3/25, showed the resident admitted to the facility on [DATE]. Review of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-05 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 107. 1. Review of the dietary supervisor's (DS) personnel records, showed a hire date of 6/13/23 and promoted to the dietary supervisor on 10/22/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. Review showed the DS had a course start date of 11/02/23 in an on-line Nutrition and Foodservice Professional Training Program. Review showed the DS had an estimated program completion date of 11/01/24. During an interview on 1/03/24 at 2:02 P.M., the DS said he/she needed to be a Certified Dietary Manager (CDM) to hold the DS position. The DS said he/she was taking classes and had finished lesson one of 17 lessons.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-05 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. The census was 107. 1. Review of the facility's Menu Alternates and Substitutions policy, reviewed 11/27/23, showed the policy did not contain guidance related to substitutions for preplanned menu items. Review of the facility's Menu Substitution Form showed the last documented food substitution was dated 11-23. 2. Review of the facility Week 1, Day 4 lunch menu, reviewed 5/30/23, showed the menu directed staff to provide residents who receive pureed meals with a #8 (four ounces) scoop of smothered steak, two ounce ladle of brown gravy, #10 (3.2 ounces) scoop pureed green beans, #20 (1.6 ounces) scoop of pureed wheat dinner roll or bread, and a #10 scoop of pureed fruit cup. Review of Week 1, Day 4 recipes showed pureed bread may be prepared separately or if added to meat 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dishwares in a manner to prevent cross-contamination when staff stacked dishwares together wet. Facility staff failed to ensure hair/beard coverings remained in place during the preparation of resident meals to prevent the potential for food contamination. The facility census was 107. 1. Review of the facility's Nutritional Services Sanitation policy, reviewed 11/27/23, showed: -Personnel shall be responsible for daily, weekly and monthly cleaning assignments as determined by the Dietary Manager and/or his/her designee; -Equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations; -Exhaust systems and hoods shall be clean,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-05 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 107. 1. Review of the facility's policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 01/05/24 at 10:15 A.M., the Director of Nursing (DON) said they do not currently have a certified IP. The Assistant Director of Nursing (ADON) is currently acting as the IP and their Regional Corporate Nurse (RNC), who is a certified IP, and himself/herself oversee IPC. He/She said he/she is not certified. He/She said it is the facility's plan the ADON is going to be the IP and the facility's wound nurse is going to be the backup IP after they both become certified. He/She said their last IP stepped down from the position in August and they have not had anyone else in that role. During an interview on 01/05/24 at 10:18 A.M., the ADON said he/she is not…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-05 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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, facility staff failed to provide residents with a dignified environment when staff did not keep residents' personal information private, allowed one resident (Resident #72) to wear the same soiled clothes for three days, left one resident (Resident #30) exposed, did not speak in a dignified manner for one resident (Resident #12) and changed the residents' smoking times for two residents (Resident #76 and #102) for staff convenience. The facility census was 107. 1. Review of the facility's Residents' [NAME] of Rights, showed staff are to treat residents with dignity and respect and are to keep residents' personal information private. 2. Observation on 01/03/24 at 11:40 A.M., Licensed Practical Nurse (LPN) K stood in the dining room with Certified Nursing Assistant (CNA) L and discussed an incident between two residents. Eight residents sat in the dining room and could hear the discussion. Observation on 01/03/24 at 12:00 P.M., LPN K and CNA L stood in the dining…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-05 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, bedrail assessments, obtain physician orders, obtain consents for the use of bed rails for four residents (Resident #4, #30, #69 and #102). The facility census was 107. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/01/23, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Parkinson's (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and Epilepsy (a seizure disorder); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent; -Obtained physicians orders. Observation on 01/02/24 at 2:52 P.M., 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2024-01-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to destroy medications in a timely manner for five current residents (Resident #41, #56, #81, #89, #92) and three discharged residents (Resident #463, #464, and #465). The facility census was 107. 1. Review of the facility's Disposal of Medications and Medication-Related Supplies policy, Revised [DATE], showed all discontinued medication will be immediately removed form the resident's active medication and stored in separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable state and federal laws. 2. Observation on [DATE] at 12:50 P.M., showed a storage closet at end of 400 hallway contained two pink basins with 33 total medication cards, one large ziplock bag with 16 medication cards, and a large plastic tub with 89 medication cards. During an interview on [DATE] at 12:50 P.M., the Director of Nursing (DON) said him/her and the Assistant Director of Nursing (ADON)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-05 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to document communication between the facility and their hospice provider for three (Resident #4, #5 and #102) out of five sampled residents who received hospice services. The facility census was 107. 1. Review of the facility's Hospice Services Agreement, dated 05/03/2023, showed hospice will prepare and maintain complete medical records for hospice patients receiving services in accordance with this agreement and will include all treatments, progress notes, authorizations, physicians orders and other pertinent information. Review showed copies of all documents of services provided by hospice will be filed and maintained in the medical record. 2. Review of Resident's #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/01/23, showed: -Recived hospice services; -A condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list, dated…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and nterview, facility staff failed to provide meals that were served at a safe and appetizing temperature for three sampled residents (Resident #1, Resident #2, and Resident #3). The facility census was 110. 1. Observation on 10/20/23 at 11:59 A.M., showed the internal temperature of the chicken tenders for Resident #1 measured 95º F upon service to the resident. During an interview on 10/20/23 at 11:01 A.M., Resident #1 said the meals served were cold. Observation on 10/20/23 at 12:14 P.M. showed the internal temperature of the chicken tenders for Resident #2 measured 99º F upon service to the resident. During an interview on 10/20/23 at 11:12 A.M., Resident #2 said meals were cold every time they were served. Observation on 10/20/23 at 12:18 P.M. showed the internal temperature of the chicken tenders for Resident #3 measured 97º F upon service to to the resident. 2. During an interview on 10/20/23 at 12:25 P.M., the cook said he/she did not know the minimum temperature hot food should be when it arrives to a resident. During an interview on 10/20/23 at 12:26…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-07-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to appropriately sanitize manually and mechanically washed dishes to prevent cross-contamination. The facility census was 109. 1. Review of the facility's Sanitation-Warewashing policy, dated 04/01/16, showed: -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines as follows: 1. All dinnerware, utensils, preparation and service supplies shall be washed and sanitized in the pot sink and/or through use of commercially approved dish machine. 4. Test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily. Observation on 07/06/22 at 10:22 A.M., showed staff washed kitchenware in the three-compartment sink. Observation showed a quaternary ammonium (QUAT) sanitizer used in the third compartment of the sink and kitchenware soaking in the sanitizer. The concentration of the sanitizer measured 100 parts per million (ppm) when measured with a QUAT test kit. Review of the product label for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-20 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 and interview, the facility staff failed to maintain a clean, safe, and comfortable homelike environment when staff failed to adequately maintain residents' rooms, common areas and hallways clean and in good repair. The facility census was 109. 1. Observation on 7/5/22 at 10:30 A.M., showed room [ROOM NUMBER] to have floor tiles with a raised black stain in the spaces between the tiles. The toilet had multiple brown smears on the toilet and tank. The door jams were heavily rusted and pitted. Observation also showed holes in the window screen. Observation on 7/5/22 at 10:40 A.M., showed room [ROOM NUMBER] to have bathroom door jams that were rusted with holes in the door jam. The base of the toilet had black stains around it. Observation on 7/5/22 at 10:45 A.M., showed room [ROOM NUMBER] to have a strong smell of urine and sticky floors. The window screen was missing in the room. Observation on 7/5/22 at 11:21 A.M., showed room [ROOM NUMBER] to have floor tiles with curled edges where the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-20 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check prior to start date for seven out of 10 sampled employees. The facility census was 109. 1. Review of the facility's Background Investigations policy, undated, showed: -Federal and State law require the facility to perform pre-employment criminal history, dependent adult abuse, and founded child abuse background checks; -Offers of employment will be conditional upon successful completion of the background checks; -Employees may not begin working until the facility has received a successful background result; -For further information, see the separate Pre-Employment Screening policy. (The facility did not provide the separate Pre-Employment Screening policy after being asked.) Review of the facility's New Hire Paperwork Checklist, undated, showed during pre-orientation, Certification/License Registry…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-20 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two (Resident #64 and #110) sampled residents. The facility's census was 109. 1. Review of facility's bed hold policy dated 03/2017 showed: - Our facility shall inform residents and/or resident representative upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed hold policy; - Upon a resident being transferred for hospitalization or for a therapeutic leave, the resident and resident representative will be provided information on the Facility Bed Hold Policy within 24 hours of the hospitalization or therapeutic leave; - A copy of the bed hold acknowledgement will be filed in the resident's record. 2. Review of Resident #64's medical record showed the following: - Staff assessed the resident as cognitively intact; - discharged to the hospital on 5/15/22 and reentered the facility on 5/18/22; - discharged to the hospital on 6/7/22 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-20 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the up to date and current number of actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 109. 1. The facility did not provide a written policy for review. Observation on 7/6/22 at 08:00 A.M. showed the daily staff assignment posting did not contain the actual hours worked by direct care nursing staff. Observation on 7/7/22 at 08:15 A.M. showed the the daily staff assignment posting did not contain the actual hours worked by direct care nursing staff Observation on 7/8/22 at 08:15 A.M. showed the the daily staff assignment posting did not contain the actual hours worked by direct care nursing staff During an interview on 7/8/22 at 12:39 P.M., the Director of Nursing said daily staffing information is posted at the front door. He/she said medical records staff are responsible for posting information daily and ensuring correct content.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria including Coronavirus Disease 2019 (COVID-19), when staff failed to perform proper hand hygiene after they touched their facemasks, and during incontinence care for two residents (Resident #35 and #45). Additionally, the facility staff failed to properly store a catheter bag for one resident (Resident #31) and ensure all employees were screened appropriately for tuberculosis (TB) by failure to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed and on file for three out of ten employee files reviewed. The facility census was 109. 1. Review of the facility's Sanitation-Handwashing policy, dated 04/01/2016, showed employees shall wash their hands after touching bare human body parts, after handling soiled equipment, when changing tasks, before donning gloves and after engaging in any activity or task…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement interventions and monitor for illegal drug use for two residents, with a history of prior illegal substance use (Resident #1 and Resident #2), when illegal drugs and paraphernalia were found in their rooms. Additionally, facility staff failed to provide safe Hoyer lift transfers for three residents (Residents #35, #95, and #107) in a manner to prevent accidents. The facility census was 109. 1. The facility records did not contain a policy for illegal substance abuse. Review of Resident #1's Annual Minimum Data Set (MDS) a federally mandated assessment tool, dated 6/12/22, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent with two plus person assist for bed mobility, transfers, dressing and toileting; -Nonverbal communication, yes or no questions; -Active diagnoses: Pneumonia, diabetes, aphasia, history of stroke, seizure disorder, traumatic brain injury and depression. Review of the resident's nursing note,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-30 · tag F0656 — failed to write and follow a full care plan — widespread
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #19, #28, #47, #91 and #109) of twelve sampled residents. The facility census was 114. 1. Review of the facility's Comprehensive Person-Centered Care Plan (CCP) policy, dated October 2019, showed: -Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care; -All disciplines will collaborate to develop a plan of care that meets residents' needs, preferences and goals; -CCP contains services provided, preferences, ability and goals for admission, desired outcomes, and care level guidelines; -The CCP can be reviewed and/or revised at quarterly intervals in conjunction with the completion of the Minimum Data Set (MDS), a federally mandated assessment tool, quarterly, significant change, and annual assessments per the Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-05-30 · tag F0679 — failed to provide activities — widespread
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet residents' interests, for the residents who reside on a secured unit. The facility census was 114. 1. Review of the facility's policy titled, Activities, dated 09/14/23, showed: -Facility is to provide an ongoing program to support residents in their choice of activities based on their comprehensive evaluation, care plan, and preferences; -Facility-Sponsored group, individual, and dependent activities will be designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the facility; -Each resident's interest and needs will be evaluated on a routine basis; -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs, these include, but are not limited to the following: -Residents exhibit unusual amounts of energy or pacing; -Residents who exhibit behaviors that require a less…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-01-05 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for four sampled residents (Resident #39, #56, #58 and #92). The facility census was 107. 1. Review of the facility's Discharge/Transfer-Involuntary Policy, last review 10/07/21, showed the policy did not include direction for staff to notify the ombudsman for resident discharge or transfer. 2. Review of an email dated, 01/02/23 at 1:42 P.M., from the Long Term Care Ombudsman Program Director showed the facility does not send him/her monthly notifications of discharged or transferred residents. 3. Review of Resident #39's medical record showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review showed the medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-01-05 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 107. 1. Review of the facility's policies showed the facility did not have a policy for staffing and scheduling Postings. Observation on 01/02/22 at 10:30 A.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. Observation on 01/03/22 at 1:33 P.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. Observation on 01/04/22 at 8:40 A.M., showed…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-05 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility staff failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for four (Resident #361, #362, #371, and #373) discharged from the facility. The facility census was 107. 1. Review of the Facility's Resident Trust Fund policy, undated, showed: -The facility is required to maintain the resident trust account balance as a positive account at all times; -Any account that reflects a negative balance must be addressed immediately to the administrator and Treasury Analyst, to be resolved immediately; -An internal audit of the resident trust will be completed on a quarterly basis by the corporate office. 2. Review of the facility's maintained Accounts Receivable Report from 01/01/23 through 01/03/24, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account discharge date #361 $1,350.00 05/02/23 #362 $2,085.00 04/21/23 #371 $1,500.00 01/22/23 #373 $1,580.00 02/24/23 Total $6,515.00 During an interview on 01/03/24…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-05-30

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 MGM HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.3-0.3 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 2 of 51.7+0.3 vs chain
Quality measures 4 of 53.6+0.4 vs chain
The other 26 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Arbor Hills Care & Rehab CenterFerguson, MO 1 of 5Bentwood Nursing & RehabFlorissant, MO 1 of 5Broadway Care & Rehab CenterMuskogee, OK 1 of 5Florissant Valley Health & Rehabilitation CenterFlorissant, MO 1 of 5Lansdowne VillageSaint Louis, MO 1 of 5Leisure Village Health Care CenterTulsa, OK 1 of 5Normandy Nursing CenterSaint Louis, MO 1 of 5Quarters At Des Peres, TheDes Peres, MO 1 of 5South Pointe Rehabilitation and Care CenterOklahoma City, OK 1 of 5Springfield Skilled Care CenterSpringfield, MO 1 of 5St Sophia Health & Rehabilitation CenterFlorissant, MO 2 of 5Eastgate Village Care & Rehab CenterMuskogee, OK 2 of 5Heritage Villa Care & Rehab CenterBartlesville, OK 2 of 5Sherbrooke VillageSaint Louis, MO 2 of 5Spring Valley Health & Rehabilitation CenterSpringfield, MO 2 of 5Walnut Grove Care & Rehab CenterMcAlester, OK 3 of 5Forest Hills Care And Rehabilitation CenterBroken Arrow, OK 3 of 5Fort Gibson Care & Rehab CenterFort Gibson, OK 3 of 5Oak Park Care CenterSaint Louis, MO 4 of 5Cleveland Care And Rehab CenterCleveland, OK 4 of 5Coweta Care & Rehab CenterCoweta, OK 4 of 5Jackson ManorJackson, MO 4 of 5Mitchell Care & Rehab CenterMcAlester, OK 4 of 5Rainbow Health Care Community And Rainbow AssistedBristow, OK 4 of 5Seminole Care And Rehabilitation CenterSeminole, OK 5 of 5Camelot Nursing And Rehabilitation CenterFarmington, MO

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
3W ACQUISITIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 02/01/2016
WEST PARK REALTY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 02/01/2016
LOWE, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 11/12/2020
JEREMIAS, BARUCHIndividualCORPORATE OFFICERsince 02/01/2016
WINTER, CHAIMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2016

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.8M
Net patient revenuemost recent cost report
-1.0%
Operating marginrevenue minus expenses
$1.3M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 6%Other / private 17%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$220per resident / day
operating cost
$6,701per month
≈ monthly operating cost
$218per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265390. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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