Cycle 1
Health 2024-10-25 · Fire 2024-10-25
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
O Fallon, MO
Abbey Senior Health
2-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
206 North Main Street, O Fallon, MO
(636) 240-5754
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,801
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0013
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.12
Baseline 23.55% · Performance 21.19% · Measure score 3.12 · Achievement 0.52 · Improvement 3.12
Healthcare-associated infections
4.54
Baseline 5.48% · Performance 6.48% · Measure score 4.54 · Achievement 4.54 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.63
Baseline 3.6 hours · Performance 4.97 hours · Measure score 6.63 · Achievement 6.63 · Improvement 5.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.7% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 265 · Observed rate 13.21% · Lower 95% interval 9.42% |
| Discharge to community | 56.85% |
50.57%
6.3 pts better
|
No Different than the National Rate · Eligible stays 272 · Observed rate 51.47% · Lower 95% interval 49.13% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.14% |
95.27%
8.1 pts worse
|
Numerator 122 · Denominator 140 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 4 · Denominator 140 |
| Discharge self-care score | 48.62% |
53.69%
5.1 pts worse
|
Numerator 53 · Denominator 109 |
| Discharge mobility score | 51.38% |
50.94%
0.4 pts better
|
Numerator 56 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 0.71% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 140 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 4.83% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 3.74% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 107 |
| Staff flu vaccination coverage | 23.29% |
42%
18.7 pts worse
|
Numerator 34 · Denominator 146 |
| Discharge function score | 60.55% |
56.45%
4.1 pts better
|
Numerator 66 · Denominator 109 |
| Transfer of health information to provider | 80.65% |
95.95%
15.3 pts worse
|
Numerator 25 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 16 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.3
2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
84.8%
1.6 pts better
|
93.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 88.2% · Q3 93.8% · Q4 63.6% · 4Q avg 86.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.1%
1.2 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 6.2% · Q4 9.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
14.7%
13.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.5%
1.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 4.5% · Q4 4.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
25.3%
4.5 pts better
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 16.0% · Q3 21.7% · Q4 22.2% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
25.0%
22.1 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.2% |
20.3%
0.9 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.0% |
19.8%
12.2 pts worse
|
14.9%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 33.3% · Q3 27.3% · Q4 30.8% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.4%
0.7 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.2% · Q3 2.5% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
2.6%
3.7 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.0% · Q3 3.3% · Q4 12.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
18.1%
0.9 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.4% · Q3 17.3% · Q4 16.0% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.0%
1.2 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 9.1% · Q3 3.0% · Q4 5.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
66.4%
20.3 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 86.0% · Q4 58.6% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
13.4%
1 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.2%
0.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 1.9% · Q4 2.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.5% |
63.5%
18 pts better
|
79.7%
1.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.3%
1.9 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 22.6% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-09 · Fire 2023-06-09
14 health deficiencies
Top issue: Administration (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-11-07 · Fire 2019-11-07
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
F · Potential for more than minimal harm
2024-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-13
F · Potential for more than minimal harm
2023-06-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-06-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-24
F · Potential for more than minimal harm
2019-11-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-11-07
F · Potential for more than minimal harm
2019-11-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-07
F · Potential for more than minimal harm
2019-11-07
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-11-07
F · Potential for more than minimal harm
2019-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
D · Potential for more than minimal harm
2024-12-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-15
F · Potential for more than minimal harm
2024-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-12-13
B · Minimal harm
2024-10-25
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-13
B · Minimal harm
2024-10-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-13
G · Actual harm
2023-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-09
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-09
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F849 · Administration Deficiencies
Health
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.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-07-24
E · Potential for more than minimal harm
2019-11-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-20
Penalties and ownership
What sits behind the stars
$0
2023-06-09
Payment Denial
Payment Denial · denial start 2023-07-13 · 11 days
11 day denial
Ownership
Abbey Health Group LLC
5% Or Greater Direct Ownership Interest · Organization
Abbey Health Group LLC
General Partnership Interest · Organization
Abbey Health Group LLC
5% Or Greater Security Interest · Organization
Brown, C Christopher
5% Or Greater Direct Ownership Interest · Individual
Brown, C Christopher
Operational/Managerial Control · Individual
Brown, C Christopher
Corporate Officer · Individual
Mount Carmel Seniro Living O'fallon LLC
5% Or Greater Mortgage Interest · Organization
Patwardhan, Manisha
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Sunterra Springs Dardenne Prairie
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