Cycle 1
Health 2025-03-12 · Fire 2025-03-12
19 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Potosi, MO
Gardens Health And Rehab, The
1-star overall rating with 3-star inspections with $8,021 in total fines with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1 Georgian Gardens Drive, Potosi, MO
(573) 438-6261
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prime Healthcare Management
Operator or chain grouping
Approved since
1992-11-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 1 overall / 2 health / 1 staffing / 2 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
0.39
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.73
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.69
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.39
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,580
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.5
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 75.00% · Performance 76.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.7
Baseline 2.64 hours · Performance 3.01 hours · Measure score 0.7 · Achievement 0 · Improvement 0.7
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 15.38% · Lower 95% interval 7.29% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · 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 | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.3 |
2.3
2 pts worse
|
1.8
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.8 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.0% |
84.8%
14.8 pts worse
|
93.4%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.9% · Q2 67.6% · Q3 82.9% · Q4 65.3% · 4Q avg 70.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 65.4% |
90.9%
25.5 pts worse
|
95.5%
30.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 65.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.1%
1 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.8% · Q3 4.9% · Q4 3.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
14.7%
7 pts better
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.8% · Q3 8.9% · Q4 6.7% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.5%
0.3 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.8% · Q3 5.7% · Q4 5.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.1% |
25.3%
11.8 pts worse
|
19.6%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 32.8% · Q3 35.2% · Q4 41.0% · 4Q avg 37.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.1% |
25.0%
13.1 pts worse
|
16.7%
21.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 31.9% · Q3 32.7% · Q4 50.0% · 4Q avg 38.1% · 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 | 19.2% |
20.3%
1.1 pts better
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 24.7% · Q3 23.5% · Q4 19.2% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
19.8%
0.4 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 14.8% · Q3 19.1% · Q4 31.7% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.4%
1.3 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 2.6% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 2.5% · Q4 2.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
18.1%
3.3 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 21.7% · Q3 11.2% · Q4 16.5% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.0%
1.8 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.8% · Q3 7.4% · Q4 7.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.0% |
66.4%
9.4 pts worse
|
81.7%
24.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.3% · Q2 61.5% · Q3 58.4% · Q4 59.6% · 4Q avg 57.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
13.4%
1.8 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 20.0% · Expected 14.7% · 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 4.0% · Q2 2.6% · Q3 3.3% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.9% |
63.5%
2.6 pts worse
|
79.7%
18.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
25.3%
6.2 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 25.0% · Expected 31.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-11-05 · Fire 2021-11-05
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
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 2025-04-26
F · Potential for more than minimal harm
2025-03-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-26
F · Potential for more than minimal harm
2025-03-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-26
F · Potential for more than minimal harm
2023-10-27
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 2023-12-08
F · Potential for more than minimal harm
2023-10-27
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 2023-12-08
F · Potential for more than minimal harm
2021-11-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-11-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-11-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-12
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 2025-04-26
D · Potential for more than minimal harm
2025-03-12
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-26
J · Immediate jeopardy
2024-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-08-23
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-30
E · Potential for more than minimal harm
2023-10-27
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 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
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 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-09-12
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 2023-09-06
D · Potential for more than minimal harm
2021-11-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-05
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 2021-12-10
D · Potential for more than minimal harm
2021-11-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-05
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 2021-12-10
Penalties and ownership
What sits behind the stars
$8,021
2024-12-18
Fine
Fine · fine $8,021
Fine
$0
2024-12-18
Payment Denial
Payment Denial · denial start 2025-01-23 · 8 days
8 day denial
Ownership
Blue Sky Basin LLC
5% Or Greater Direct Ownership Interest · Organization
Sloans Lake Trust
5% Or Greater Indirect Ownership Interest · Organization
Dkdp Missouri LLC
5% Or Greater Direct Ownership Interest · Organization
Perlow, Bernard
5% Or Greater Indirect Ownership Interest · Individual
Dkyh Missouri LLC
5% Or Greater Direct Ownership Interest · Organization
Kleiner, Dovid
5% Or Greater Indirect Ownership Interest · Individual
Berger, Eliot
Corporate Director · Individual
Mayfield, Suzanne
W-2 Managing Employee · Individual
Perlow, Bernard
Corporate Director · Individual
Stern, Samuel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Potosi Manor
Potosi, MO
1-star overall rating with 3-star inspections with $13,627 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
St Joe Manor
Bonne Terre, MO
2-star overall rating with 4-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Desloge
Desloge, MO
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out