16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Edina, MO
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
55774 State Highway 6, Edina, MO
(660) 397-2282
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
38
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-06-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.55
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.27
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Program rank
4,176
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
0
Performance 9.92% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.68
Baseline 65.62% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 6.68
Adjusted total nurse staffing
5.63
Baseline 3.19 hours · Performance 4.68 hours · Measure score 5.63 · Achievement 5.63 · Improvement 5.24
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.08% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 22.73% · Lower 95% interval 8.73% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| 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 | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.92% |
7.12%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 22.22% · Lower 95% interval 6.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 33.33% |
42%
8.7 pts worse
|
Numerator 38 · Denominator 114 |
| 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 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.3
1.6 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
84.8%
12.5 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 88.6% · 4Q avg 97.3% |
| 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 | 12.3% |
4.1%
8.2 pts worse
|
3.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 10.5% · Q3 17.1% · Q4 11.4% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
14.7%
12.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 0.0% · Q4 3.1% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.5% · Q3 3.0% · Q4 3.1% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
25.3%
0.2 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 30.6% · Q3 26.5% · Q4 20.6% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
25.0%
8.3 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 12.9% · Q3 19.2% · Q4 22.2% · 4Q avg 16.7% · 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 | 14.2% |
20.3%
6.1 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 18.0% · Q4 4.2% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.9% |
19.8%
0.1 pts worse
|
14.9%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 20.6% · Q3 21.2% · Q4 18.2% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.0% |
1.4%
4.6 pts worse
|
1.0%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 3.4% · Q3 5.3% · Q4 5.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.9% |
2.6%
10.3 pts worse
|
1.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 17.6% · Q3 11.8% · Q4 15.2% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
18.1%
6.3 pts better
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 11.3% · Q3 11.0% · Q4 20.2% · 4Q avg 11.8% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.0%
1.4 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.2% · Q4 6.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
66.4%
26.6 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.8% |
13.4%
11.4 pts worse
|
12.0%
12.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 21.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.3% |
25.3%
13 pts worse
|
23.9%
14.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.3% · Observed 39.1% · Expected 24.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-03-01
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-03-01
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-01
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-01
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-01
Fire Safety
Establish emergency prep training and testing.
Corrected 2020-11-27
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-11-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-11-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-11-27
Fire Safety
Use approved construction type or materials.
Corrected 2020-11-27
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-11-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-11-27
Fire Safety
Use approved construction type or materials.
Corrected 2019-04-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-04-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-05
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-04-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-04-05
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-04-05
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-04-05
Fire Safety
Develop a communication plan.
Corrected 2019-04-05
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-04-05
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-04-05
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-04-05
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-04-05
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-19
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 2024-03-01
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-03-01
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-01
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-03-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-01
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
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 2024-03-01
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-01
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 2024-03-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-01
Health
Post nurse staffing information every day.
Corrected 2024-03-01
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 2020-11-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-11-27
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-11-27
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-11-27
Health
Provide and implement an infection prevention and control program.
Corrected 2020-11-27
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2020-11-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-11-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-11-27
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 2020-11-27
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2020-11-27
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2020-11-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-04-05
Health
Implement a program that monitors antibiotic use.
Corrected 2019-04-05
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2019-04-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-04-05
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 2019-04-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-04-05
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-04-05
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-04-05
Penalties and ownership
Payment Denial · denial start 2025-09-17 · 2 days
2 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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