Cycle 1
Health 2025-09-19 · Fire 2025-09-19
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Liberty, MO
Avalon View Health And Wellness
2-star overall rating with 3-star inspections with $14,267 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1200 West College Street, Liberty, MO
(816) 781-3020
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vertical Health Services
Operator or chain grouping
Approved since
1990-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 1 staffing / 4 quality stars
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
0.25
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.42
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,540
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.78
Performance 20.14% · Measure score 2.78 · Achievement 2.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.66
Baseline 9.74% · Performance 8.71% · Measure score 1.66 · Achievement 0 · Improvement 1.66
Total nurse turnover
2.12
Baseline 63.44% · Performance 55.00% · Measure score 2.12 · Achievement 2.12 · Improvement 1.69
Adjusted total nurse staffing
0
Baseline 3.64 hours · Performance 1.90 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.56% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 23.08% · Lower 95% interval 8.46% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 38 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.03% |
| Healthcare-associated infections requiring hospitalization | 8.71% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 16.13% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 7.55% |
8.2%
0.6 pts worse
|
Numerator 8 · Denominator 106 |
| Staff flu vaccination coverage | 5.79% |
42%
36.2 pts worse
|
Numerator 21 · Denominator 363 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
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 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
84.8%
15 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 1.7% |
4.1%
2.4 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 1.9% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 86.6% |
14.7%
71.9 pts worse
|
11.4%
75.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 89.8% · Q3 77.8% · Q4 86.5% · 4Q avg 86.6% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
5.5%
3.1 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 13.3% · Q3 1.1% · Q4 6.5% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.2% |
25.3%
8.9 pts worse
|
19.6%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 34.9% · Q3 31.9% · Q4 37.2% · 4Q avg 34.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.7% |
25.0%
11.7 pts worse
|
16.7%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.6% · Q2 37.5% · Q3 33.3% · Q4 32.4% · 4Q avg 36.7% · 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 | 3.6% |
20.3%
16.7 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 5.5% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.1% |
19.8%
17.7 pts better
|
14.9%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.8% · Q3 2.4% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
18.1%
4 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 24.1% · Q3 23.5% · Q4 23.0% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.0%
1.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.3% · Q3 2.3% · Q4 2.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
66.4%
17.6 pts better
|
81.7%
2.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 76.8% · Q3 80.0% · Q4 95.2% · 4Q avg 84.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
13.4%
5.1 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 9.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
2.2%
0.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
63.5%
13.2 pts better
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
25.3%
3.8 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 23.8% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-23 · Fire 2024-09-23
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-12-14 · Fire 2023-12-14
22 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-30
F · Potential for more than minimal harm
2025-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-09-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-30
L · Immediate jeopardy
2024-09-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-16
F · Potential for more than minimal harm
2023-12-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
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 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-10
E · Potential for more than minimal harm
2025-09-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-09-19
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 2025-08-25
D · Potential for more than minimal harm
2025-04-02
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 2025-03-24
E · Potential for more than minimal harm
2024-09-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
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 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-23
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 2024-10-30
E · Potential for more than minimal harm
2024-09-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
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 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-02-12
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-02-12
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-02-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-12-14
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 2024-03-14
E · Potential for more than minimal harm
2023-12-14
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-12-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-12-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-14
E · Potential for more than minimal harm
2023-12-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
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 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-14
D · Potential for more than minimal harm
2023-12-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-07-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-05-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
$14,267
2024-09-23
Fine
Fine · fine $14,267
Fine
Ownership
College St Consulting LLC
Operational/Managerial Control · Organization
Gatapia, Ramilo
Operational/Managerial Control · Individual
Miller, William
Operational/Managerial Control · Individual
Siard, Ashlee
Operational/Managerial Control · Individual
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