Cycle 1
Health 2025-08-11 · Fire 2025-08-11
18 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Macon, MO
Loch Haven
2-star overall rating with 2-star inspections with $77,841 in total fines with 18 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
701 Sunset Hills Dr, Macon, MO
(660) 385-3113
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
71
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-08-01
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
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.70
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.25
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,152
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.48
Baseline 17.99% · Performance 20.28% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Healthcare-associated infections
5.58
Baseline 6.16% · Performance 6.17% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Total nurse turnover
1.99
Performance 55.56% · Measure score 1.99 · Achievement 1.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.84
Baseline 5.73 hours · Performance 4.46 hours · Measure score 4.84 · Achievement 4.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 5.88% · Lower 95% interval 5.85% |
| Discharge to community | 47.24% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 43.33% · Lower 95% interval 36.97% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75% |
95.27%
20.3 pts worse
|
Numerator 15 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| 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 | 10% |
2.29%
7.7 pts worse
|
Numerator 2 · Denominator 20 · Adjusted rate 12.63% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 2.27% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 6.32% |
8.2%
1.9 pts worse
|
Numerator 6 · Denominator 95 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · 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 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.3
1.4 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
84.8%
8.9 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 92.8% · Q3 95.4% · Q4 93.0% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
90.9%
7.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
4.1%
2.2 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.2% · Q3 7.7% · Q4 5.6% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
14.7%
12.6 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 1.7% · Q4 3.2% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.5%
1.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.6% · Q3 1.8% · Q4 3.4% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
25.3%
5.7 pts better
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.3% · Q3 21.8% · Q4 24.2% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.8% |
25.0%
4.8 pts worse
|
16.7%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 26.8% · Q3 32.5% · Q4 34.1% · 4Q avg 29.8% · 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 | 10.3% |
20.3%
10 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 14.0% · Q3 10.2% · Q4 8.4% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
19.8%
0.8 pts better
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 22.8% · Q3 9.4% · Q4 22.0% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.2% |
2.6%
3.6 pts worse
|
1.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 6.2% · Q3 3.1% · Q4 5.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
18.1%
1.6 pts better
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 13.2% · Q3 25.3% · Q4 15.8% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
5.0%
4.9 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 9.4% · Q3 13.2% · Q4 6.9% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.4% |
66.4%
7 pts better
|
81.7%
8.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 80.0% · Q3 70.8% · 4Q avg 73.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
13.4%
1.6 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
2.2%
0.7 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
63.5%
21.5 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.5% |
25.3%
15.8 pts better
|
23.9%
14.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 7.4% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2020-01-16 · Fire 2020-01-16
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-08-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-23
E · Potential for more than minimal harm
2023-11-02
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2020-01-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-16
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-28
F · Potential for more than minimal harm
2020-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
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 2025-09-23
F · Potential for more than minimal harm
2025-08-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
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 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-11
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 2025-09-23
D · Potential for more than minimal harm
2025-08-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-09-23
C · Minimal harm
2025-08-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-23
G · Actual harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-14
J · Immediate jeopardy
2024-03-12
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 2024-04-01
F · Potential for more than minimal harm
2023-11-02
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 2023-12-15
E · Potential for more than minimal harm
2023-11-02
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-06-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-17
F · Potential for more than minimal harm
2020-01-16
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 2020-02-28
E · Potential for more than minimal harm
2020-01-16
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 2020-02-28
E · Potential for more than minimal harm
2020-01-16
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 2020-02-28
E · Potential for more than minimal harm
2020-01-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-02-28
E · Potential for more than minimal harm
2020-01-16
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 2020-02-28
E · Potential for more than minimal harm
2020-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-16
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 2020-02-28
Penalties and ownership
What sits behind the stars
$69,820
2025-03-07
Fine
Fine · fine $69,820
Fine
$8,021
2024-03-12
Fine
Fine · fine $8,021
Fine
Ownership
Freeman, Byron
Corporate Director · Individual
Freeman, Byron
W-2 Managing Employee · Individual
Hinshaw, Kelsey
Corporate Director · Individual
Hinshaw, Kelsey
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Macon Health Care Center
Macon, MO
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Clarence Care Center
Clarence, MO
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
La Plata Nursing Home
La Plata, MO
3-star overall rating with 3-star inspections with $173,534 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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