Cycle 1
Health 2024-08-22 · Fire 2024-08-22
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Chesterfield, MO
Mason Pointe Care Center
5-star overall rating with 5-star inspections with $19,460 in total fines with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
13190 South Outer 40 Road, Chesterfield, MO
(417) 932-8040
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Evertrue
Operator or chain grouping
Approved since
1995-05-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 5 overall / 5 health / 5 staffing / 4 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
1.00
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,076
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.17% · Performance 22.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.46
Baseline 6.21% · Performance 6.80% · Measure score 3.46 · Achievement 3.46 · Improvement 0
Total nurse turnover
4.63
Baseline 46.90% · Performance 44.74% · Measure score 4.63 · Achievement 4.63 · Improvement 0.48
Adjusted total nurse staffing
5.54
Baseline 5.48 hours · Performance 4.65 hours · Measure score 5.54 · Achievement 5.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.01% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 17.74% · Lower 95% interval 8.4% |
| Discharge to community | 42.81% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 35.14% · Lower 95% interval 32.6% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 10 · Denominator 24 |
| Discharge mobility score | 16.67% |
50.94%
34.3 pts worse
|
Numerator 4 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 1.47% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 68 |
| Staff flu vaccination coverage | 94.94% |
42%
52.9 pts better
|
Numerator 75 · Denominator 79 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 10 · Denominator 24 |
| 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 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.3
1.7 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
84.8%
8.5 pts better
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 90.2% · Q3 95.2% · Q4 100.0% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
90.9%
6.1 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
4.1%
0.3 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.9% · Q3 2.4% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
14.7%
14.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.6% |
| 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 8.5% · Q2 3.9% · Q3 3.0% · Q4 0.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
25.3%
10.9 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.7% · Q3 23.5% · Q4 23.5% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
25.0%
12.2 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.4% · Q3 14.8% · Q4 18.5% · 4Q avg 12.8% · 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 | 11.4% |
20.3%
8.9 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 4.0% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
19.8%
8.6 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.4% · Q3 13.3% · Q4 20.7% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.4%
0.2 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.7% · Q3 2.4% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
18.1%
5.5 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 14.4% · Q3 13.4% · Q4 11.6% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.0%
0.8 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.5% · Q3 5.1% · Q4 1.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.0% |
66.4%
2.4 pts worse
|
81.7%
17.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 72.7% · Q4 51.9% · 4Q avg 64.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.4%
13.4 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
63.5%
27 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
25.3%
11.3 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 11.1% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-12 · Fire 2023-07-12
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-06-11 · Fire 2019-06-11
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-20
F · Potential for more than minimal harm
2024-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-08-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-08-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-20
E · Potential for more than minimal harm
2024-08-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-16
F · Potential for more than minimal harm
2023-07-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2019-06-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-25
E · Potential for more than minimal harm
2019-06-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-07-25
E · Potential for more than minimal harm
2019-06-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-12-11
E · Potential for more than minimal harm
2019-06-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-07-25
E · Potential for more than minimal harm
2019-06-11
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 2019-07-25
E · Potential for more than minimal harm
2019-06-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-30
J · Immediate jeopardy
2023-04-13
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 2023-03-31
E · Potential for more than minimal harm
2019-06-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-07-25
E · Potential for more than minimal harm
2019-06-11
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 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
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 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
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 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
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 2019-07-25
D · Potential for more than minimal harm
2019-06-11
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 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-07-25
Penalties and ownership
What sits behind the stars
$19,460
2023-04-13
Fine
Fine · fine $19,460
Fine
Ownership
Lutheran Senior Services
5% Or Greater Direct Ownership Interest · Organization
Anderson, David
Corporate Director · Individual
Bantle, Julie
Corporate Director · Individual
Beumer, Brent
Corporate Director · Individual
Brown, Daniel
Corporate Director · Individual
Christell, Roy
Corporate Director · Individual
Drollinger, Diane
Corporate Director · Individual
Dunn, Jeffrey
Corporate Director · Individual
Kuhlmann, Frederick
Corporate Director · Individual
Marles, Adam
Corporate Director · Individual
Marles, Adam
Corporate Officer · Individual
Marles, Adam
W-2 Managing Employee · Individual
Mccline, Elise
Corporate Director · Individual
Meadows, Megan
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Schaefer, Ronald
Corporate Officer · Individual
Schaefer, Ronald
W-2 Managing Employee · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sneed, Chadwick
W-2 Managing Employee · Individual
Sombart, Lisa
Corporate Director · Individual
Sommer, Christopher
Corporate Director · Individual
Tice, Paul
Corporate Director · Individual
Toon, Norman
Corporate Director · Individual
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#2
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3-star overall rating with 3-star inspections with $15,646 in total fines with 18 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Garden View Care Center Of Chesterfield
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4-star overall rating with 4-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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