Cycle 1
Health 2024-07-16 · Fire 2024-07-16
35 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Saint Louis, MO
Hillside Health Care Center
1-star overall rating with 1-star inspections with Special Focus status with $126,156 in total fines with 35 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
1265 Mclaran Avenue, Saint Louis, MO
(314) 388-4121
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
208
Certified beds
Average residents
145
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ama Holdings
Operator or chain grouping
Approved since
1994-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 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
0.33
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.11
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
2.58
Performance 7.06% · Measure score 2.58 · Achievement 2.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 64.84% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.05
Baseline 3.7 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 5.41% · Lower 95% interval 5.24% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.08% |
95.27%
0.8 pts better
|
Numerator 49 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 14 · Denominator 30 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 9 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 3 · Denominator 51 · Adjusted rate 7.37% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 9.2% |
8.2%
1 pts better
|
Numerator 15 · Denominator 163 |
| Staff flu vaccination coverage | 7.94% |
42%
34.1 pts worse
|
Numerator 17 · Denominator 214 |
| Discharge function score | 53.33% |
56.45%
3.1 pts worse
|
Numerator 16 · Denominator 30 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 6 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.8% |
84.8%
9 pts worse
|
93.4%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 70.3% · Q3 58.2% · Q4 88.2% · 4Q avg 75.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 39.0% |
90.9%
51.9 pts worse
|
95.5%
56.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 39.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.1%
0.8 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.7% · Q3 2.1% · Q4 2.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.2% |
14.7%
45.5 pts worse
|
11.4%
48.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 60.0% · Q3 33.1% · Q4 65.4% · 4Q avg 60.2% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.5%
1.7 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.7% · Q3 4.7% · Q4 2.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
25.3%
10.1 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 18.3% · Q3 13.3% · Q4 13.8% · 4Q avg 15.2% |
| 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 | 19.5% |
20.3%
0.8 pts better
|
16.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 22.5% · Q3 20.8% · Q4 20.7% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
19.8%
5.7 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 32.6% · Q3 31.5% · Q4 22.8% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.4%
0.9 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
18.1%
3.8 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 26.3% · Q3 20.7% · Q4 17.1% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.0%
2.9 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.9% · Q4 3.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 18.7% |
66.4%
47.7 pts worse
|
81.7%
63 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 8.3% · Q3 6.1% · Q4 32.0% · 4Q avg 18.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
13.4%
2.2 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.9% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 12.5% |
63.5%
51 pts worse
|
79.7%
67.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 12.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.1% |
25.3%
9.8 pts worse
|
23.9%
11.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.1% · Observed 26.2% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-25 · Fire 2022-01-25
28 health deficiencies
Top issue: Resident Rights (13 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-12-24 · Fire 2019-12-24
48 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Not marked corrected
E · Potential for more than minimal harm
2024-07-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-26
F · Potential for more than minimal harm
2022-01-25
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-10
F · Potential for more than minimal harm
2019-12-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2020-01-28
F · Potential for more than minimal harm
2019-12-24
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2020-01-28
F · Potential for more than minimal harm
2019-12-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-01-28
F · Potential for more than minimal harm
2019-12-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
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 2020-01-28
Inspection history
Recent health citations
G · Actual harm
2025-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-26
G · Actual harm
2025-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-26
G · Actual harm
2025-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-26
G · Actual harm
2025-02-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-06
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-06
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 2025-03-03
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-11-05
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-05
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 2024-11-26
D · Potential for more than minimal harm
2024-11-05
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 2024-11-26
J · Immediate jeopardy
2024-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-26
J · Immediate jeopardy
2024-07-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-26
J · Immediate jeopardy
2024-07-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-26
G · Actual harm
2024-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-26
G · Actual harm
2024-07-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-26
G · Actual harm
2024-07-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-16
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 2024-08-26
F · Potential for more than minimal harm
2024-07-16
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-16
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 2024-08-26
F · Potential for more than minimal harm
2024-07-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
E · Potential for more than minimal harm
2024-07-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-16
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 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
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 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
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 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
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 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-16
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-08-26
C · Minimal harm
2024-07-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-01-19
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 2024-02-07
D · Potential for more than minimal harm
2023-11-08
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 2023-09-28
D · Potential for more than minimal harm
2023-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-08
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 2023-11-20
F · Potential for more than minimal harm
2023-09-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-14
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 2023-11-20
L · Immediate jeopardy
2023-08-01
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 2023-08-03
E · Potential for more than minimal harm
2023-07-14
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 2023-08-03
E · Potential for more than minimal harm
2023-07-14
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 2023-08-24
E · Potential for more than minimal harm
2023-07-14
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-24
E · Potential for more than minimal harm
2023-03-30
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 2023-04-18
E · Potential for more than minimal harm
2023-03-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-03-30
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-18
G · Actual harm
2022-01-25
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 2022-03-10
F · Potential for more than minimal harm
2022-01-25
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-03-10
F · Potential for more than minimal harm
2022-01-25
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
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 2022-03-10
E · Potential for more than minimal harm
2022-01-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
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 2022-03-10
E · Potential for more than minimal harm
2022-01-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-25
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 2022-03-10
D · Potential for more than minimal harm
2022-01-25
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 2022-03-10
D · Potential for more than minimal harm
2022-01-25
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-25
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 2022-03-10
D · Potential for more than minimal harm
2022-01-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-03-10
C · Minimal harm
2022-01-25
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 2022-03-10
L · Immediate jeopardy
2019-12-24
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2020-01-28
G · Actual harm
2019-12-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-01-28
F · Potential for more than minimal harm
2019-12-24
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 2020-02-11
F · Potential for more than minimal harm
2019-12-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
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 2020-01-28
E · Potential for more than minimal harm
2019-12-24
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 2020-01-28
E · Potential for more than minimal harm
2019-12-24
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 2020-01-28
E · Potential for more than minimal harm
2019-12-24
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 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-01-28
E · Potential for more than minimal harm
2019-12-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
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 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
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 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
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 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-01-28
D · Potential for more than minimal harm
2019-12-24
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2020-01-28
Penalties and ownership
What sits behind the stars
$11,492
2025-02-06
Fine
Fine · fine $11,492
Fine
$95,096
2024-07-16
Fine
Fine · fine $95,096
Fine
$0
2024-07-16
Payment Denial
Payment Denial · denial start 2024-08-27 · 9 days
9 day denial
$19,568
2023-07-14
Fine
Fine · fine $19,568
Fine
Ownership
Mo Operation Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ama Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Def Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Jones, Rebeka
W-2 Managing Employee · Individual
Marx, Asher
5% Or Greater Indirect Ownership Interest · Individual
Marx, Asher
Corporate Director · Individual
Wolf, Jacques
5% Or Greater Indirect Ownership Interest · Individual
Wolf, Jacques
Corporate Director · Individual
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