Cycle 1
Health 2024-08-08 · Fire 2024-08-08
22 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Saint Charles, MO
Lewis & Clark Gardens
1-star overall rating with 1-star inspections with abuse icon flag with $139,916 in total fines with 22 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1221 Boones Lick Road, Saint Charles, MO
(636) 946-6140
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1982-02-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.28
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.75
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,940
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
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
1.50
Baseline 53.45% · Performance 57.53% · Measure score 1.50 · Achievement 1.50 · Improvement 0
Adjusted total nurse staffing
3.54
Baseline 3.79 hours · Performance 4.09 hours · Measure score 3.54 · Achievement 3.54 · Improvement 0.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · 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 13 · 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 114 |
| Staff flu vaccination coverage | 0.85% |
42%
41.1 pts worse
|
Numerator 1 · Denominator 118 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
84.8%
6.3 pts better
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 88.9% · Q3 93.2% · Q4 95.4% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
90.9%
5.7 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.9% |
4.1%
5.8 pts worse
|
3.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.9% · Q3 12.3% · Q4 7.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
14.7%
13.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
5.5%
5.1 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.8% |
25.3%
20.5 pts better
|
19.6%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 6.1% · Q4 6.8% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
25.0%
4.4 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 20.0% · Q3 20.9% · Q4 17.9% · 4Q avg 20.6% · 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 | 17.5% |
20.3%
2.8 pts better
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 23.2% · Q3 16.2% · Q4 10.6% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
19.8%
0.6 pts better
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 26.1% · Q3 15.6% · Q4 6.9% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.4%
1.1 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 1.9% · Q3 1.2% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.6%
1.7 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.9% · Q3 6.8% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
18.1%
0.6 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 25.4% · Q3 17.3% · Q4 10.6% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.0%
4.3 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.3% · Q3 6.5% · Q4 10.8% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 27.1% |
66.4%
39.3 pts worse
|
81.7%
54.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 36.0% · Q3 16.0% · Q4 16.3% · 4Q avg 27.1% |
| 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 | 8.3% |
63.5%
55.2 pts worse
|
79.7%
71.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 8.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-02 · Fire 2022-12-02
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-06-18 · Fire 2019-06-18
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-19
F · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-02
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 2023-01-06
E · Potential for more than minimal harm
2022-12-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-02
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 2023-01-06
F · Potential for more than minimal harm
2019-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-31
F · Potential for more than minimal harm
2019-06-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-07-31
F · Potential for more than minimal harm
2019-06-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
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 2019-07-31
E · Potential for more than minimal harm
2019-06-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-07-31
C · Minimal harm
2019-06-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-07-31
C · Minimal harm
2019-06-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-31
C · Minimal harm
2019-06-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-07-31
C · Minimal harm
2019-06-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-07-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-11-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-09-15
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 2025-10-15
G · Actual harm
2025-06-23
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 2025-08-20
D · Potential for more than minimal harm
2025-06-23
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 2025-08-20
D · Potential for more than minimal harm
2025-06-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-06-23
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 2025-08-20
D · Potential for more than minimal harm
2025-05-13
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 2025-05-05
J · Immediate jeopardy
2025-04-24
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 2025-04-18
D · Potential for more than minimal harm
2025-04-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-04
E · Potential for more than minimal harm
2024-10-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-08-08
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 2024-09-19
E · Potential for more than minimal harm
2024-08-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-08-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-08-08
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 2024-11-07
E · Potential for more than minimal harm
2024-08-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-08-08
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 2024-09-19
E · Potential for more than minimal harm
2024-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-08-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-08
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-06-26
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 2024-07-17
D · Potential for more than minimal harm
2024-06-26
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 2024-07-17
J · Immediate jeopardy
2024-05-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-15
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 2024-07-17
D · Potential for more than minimal harm
2024-05-15
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 2024-07-17
E · Potential for more than minimal harm
2023-12-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-05
E · Potential for more than minimal harm
2023-12-27
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 2024-02-05
E · Potential for more than minimal harm
2023-12-27
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 2024-02-05
D · Potential for more than minimal harm
2023-12-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-27
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 2024-02-05
D · Potential for more than minimal harm
2023-12-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-05
J · Immediate jeopardy
2022-12-02
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 2023-01-06
D · Potential for more than minimal harm
2022-12-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-02
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 2023-01-06
F · Potential for more than minimal harm
2019-06-18
F803 · Nutrition and Dietary Deficiencies
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 2019-07-31
F · Potential for more than minimal harm
2019-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
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 2019-07-31
E · Potential for more than minimal harm
2019-06-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-18
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 2019-07-31
E · Potential for more than minimal harm
2019-06-18
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 2019-07-31
E · Potential for more than minimal harm
2019-06-18
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 2019-07-31
E · Potential for more than minimal harm
2019-06-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
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 2019-07-31
D · Potential for more than minimal harm
2019-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
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 2019-07-31
D · Potential for more than minimal harm
2019-06-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
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 2019-07-31
D · Potential for more than minimal harm
2019-06-18
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
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 2019-07-31
D · Potential for more than minimal harm
2019-06-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-18
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 2019-07-31
C · Minimal harm
2019-06-18
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 2019-07-31
Penalties and ownership
What sits behind the stars
$63,427
2025-06-23
Fine
Fine · fine $63,427
Fine
$17,300
2025-04-24
Fine
Fine · fine $17,300
Fine
$59,189
2024-05-15
Fine
Fine · fine $59,189
Fine
$0
2024-05-15
Payment Denial
Payment Denial · denial start 2024-06-14 · 33 days
33 day denial
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Ltc Management Services LLC
Operational/Managerial Control · Organization
Yates, Melissa
W-2 Managing Employee · Individual
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