Cycle 1
Health 2025-03-24 · Fire 2025-03-24
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Shrewsbury, MO
Mary, Queen And Mother Center
2-star overall rating with 2-star inspections with $19,133 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
7601 Watson Road, Shrewsbury, MO
(314) 961-8000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
217
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,320
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.99% · Performance 21.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.20
Baseline 5.93% · Performance 6.28% · Measure score 5.20 · Achievement 5.20 · Improvement 0
Total nurse turnover
4.33
Performance 45.98% · Measure score 4.33 · Achievement 4.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.50
Baseline 3.67 hours · Performance 3.79 hours · Measure score 2.50 · Achievement 2.50 · Improvement 0.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.59% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 13.28% · Lower 95% interval 9.33% |
| Discharge to community | 50.83% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 46.96% · Lower 95% interval 44.26% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 84.48% |
95.27%
10.8 pts worse
|
Numerator 49 · Denominator 58 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 58 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 22 · Denominator 44 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 12 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 1.48% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 3.75% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 0.82% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 122 |
| Staff flu vaccination coverage | 96.86% |
42%
54.9 pts better
|
Numerator 154 · Denominator 159 |
| Discharge function score | 38.64% |
56.45%
17.8 pts worse
|
Numerator 17 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 86.21% |
96.28%
10.1 pts worse
|
Numerator 25 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 23.33% |
25.2%
1.9 pts worse
|
Numerator 7 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
84.8%
10.4 pts better
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 95.8% · Q3 94.2% · Q4 93.2% · 4Q avg 95.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
90.9%
6.5 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
4.1%
1.8 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.2% · Q3 7.2% · Q4 5.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
14.7%
7.8 pts better
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.7% · Q3 8.2% · Q4 5.7% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.5%
2.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 1.9% · Q3 1.9% · Q4 4.1% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
25.3%
8.9 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 18.5% · Q4 16.3% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
25.0%
7.3 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.0% · Q3 21.6% · Q4 29.4% · 4Q avg 17.7% · 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 | 10.6% |
20.3%
9.7 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 10.8% · Q3 6.6% · Q4 13.7% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
19.8%
10.1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.3% · Q3 11.5% · Q4 4.3% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.4%
0.1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 9.2% |
18.1%
8.9 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.9% · Q3 5.2% · Q4 9.0% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.0%
2.7 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.0% · Q3 3.1% · Q4 1.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.1% |
66.4%
3.3 pts worse
|
81.7%
18.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.3% · Q2 63.1% · Q3 57.4% · Q4 57.3% · 4Q avg 63.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
13.4%
5.6 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.2%
0.9 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 0.0% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.0% |
63.5%
0.5 pts better
|
79.7%
15.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
25.3%
3.3 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 20.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-08 · Fire 2024-01-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2021-10-18 · Fire 2021-10-18
25 health deficiencies
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-24
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 2025-05-05
E · Potential for more than minimal harm
2025-03-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
F · Potential for more than minimal harm
2024-01-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-08
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 2024-02-23
E · Potential for more than minimal harm
2024-01-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-08
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 2024-02-23
E · Potential for more than minimal harm
2024-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-23
F · Potential for more than minimal harm
2021-10-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-03
F · Potential for more than minimal harm
2021-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-04-30
D · Potential for more than minimal harm
2025-11-04
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 2025-12-19
D · Potential for more than minimal harm
2025-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-19
K · Immediate jeopardy
2025-03-24
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 2025-04-25
D · Potential for more than minimal harm
2025-03-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-24
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 2025-04-25
D · Potential for more than minimal harm
2025-03-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-24
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 2025-05-05
E · Potential for more than minimal harm
2024-01-08
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 2023-10-01
E · Potential for more than minimal harm
2024-01-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-08
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 2024-02-23
D · Potential for more than minimal harm
2024-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-08
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 2024-02-23
F · Potential for more than minimal harm
2021-10-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
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 2021-12-03
E · Potential for more than minimal harm
2021-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-18
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 2021-12-03
D · Potential for more than minimal harm
2021-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-18
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 2021-12-03
D · Potential for more than minimal harm
2021-10-18
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 2021-12-03
D · Potential for more than minimal harm
2021-10-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-18
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2021-12-03
C · Minimal harm
2021-10-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-12-03
C · Minimal harm
2021-10-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-03
B · Minimal harm
2021-10-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2021-12-03
B · Minimal harm
2021-10-18
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 2021-12-03
Penalties and ownership
What sits behind the stars
$19,133
2025-03-24
Fine
Fine · fine $19,133
Fine
$0
2025-03-24
Payment Denial
Payment Denial · denial start 2025-04-26 · 9 days
9 day denial
Ownership
Klingerman, Kevin
Corporate Director · Individual
Lyons, Jamie
W-2 Managing Employee · Individual
Wesley, Sister Suzanne
Corporate Director · Individual
Nearby options
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#3
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