Cycle 1
Health 2025-12-05 · Fire 2025-12-05
14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Mound City, MO
Tiffany Heights
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1531 Nebraska Street, Mound City, MO
(660) 442-3146
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prime Healthcare Management
Operator or chain grouping
Approved since
2002-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 1 overall / 2 health / 1 staffing / 2 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
0.37
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.94
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.61
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
71%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,657
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
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
2.45
Baseline 34.38% · Performance 53.66% · Measure score 2.45 · Achievement 2.45 · Improvement 0
Adjusted total nurse staffing
3.37
Baseline 3.52 hours · Performance 4.04 hours · Measure score 3.37 · Achievement 3.37 · Improvement 1.78
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 6.17% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 88.46% |
95.27%
6.8 pts worse
|
Numerator 23 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · 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 63 |
| Staff flu vaccination coverage | 59.32% |
42%
17.3 pts better
|
Numerator 35 · Denominator 59 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
84.8%
1.5 pts worse
|
93.4%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 56.2% · Q3 100.0% · Q4 80.6% · 4Q avg 83.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.1%
1 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.2% · Q3 5.7% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
14.7%
10.4 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 5.7% · Q4 5.6% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.5%
0.3 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 9.5% · Q3 0.0% · Q4 0.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
25.3%
16 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 4.5% · Q3 13.3% · Q4 6.7% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
25.0%
19.6 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 7.7% · Q4 7.4% · 4Q avg 5.4% · 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 | 19.2% |
20.3%
1.1 pts better
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
19.8%
10.9 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 19.0% · Q3 3.6% · Q4 6.9% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.4%
0.7 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
18.1%
7.3 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 14.1% · Q3 8.0% · Q4 7.4% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.0%
2.4 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 3.2% · Q4 3.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.6% |
66.4%
7.2 pts better
|
81.7%
8.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 66.7% · 4Q avg 73.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
13.4%
7.9 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.8% · Expected 9.6% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.0% |
63.5%
38.5 pts worse
|
79.7%
54.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 43.2% |
25.3%
17.9 pts worse
|
23.9%
19.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 43.2% · Observed 38.1% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-02-17 · Fire 2023-02-17
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-05
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 2026-01-22
E · Potential for more than minimal harm
2024-08-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-02-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-02-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-02-17
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-02-17
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Not marked corrected
F · Potential for more than minimal harm
2023-02-17
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-02-17
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 2023-04-18
E · Potential for more than minimal harm
2023-02-17
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 2023-04-18
E · Potential for more than minimal harm
2023-02-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-02-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-02-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-05
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 2026-01-22
E · Potential for more than minimal harm
2025-12-05
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-05
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 2026-01-22
E · Potential for more than minimal harm
2025-12-05
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 2026-01-22
E · Potential for more than minimal harm
2025-12-05
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 2026-01-22
E · Potential for more than minimal harm
2025-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-05
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 2026-01-22
D · Potential for more than minimal harm
2025-12-05
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 2026-01-22
D · Potential for more than minimal harm
2025-12-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-05
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 2026-01-22
D · Potential for more than minimal harm
2025-12-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-05
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-22
E · Potential for more than minimal harm
2024-08-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
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 2024-10-11
E · Potential for more than minimal harm
2024-08-29
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 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
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 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
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 2024-10-11
D · Potential for more than minimal harm
2024-08-29
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 2024-10-11
E · Potential for more than minimal harm
2023-02-17
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 2023-04-18
Penalties and ownership
What sits behind the stars
Ownership
Gateway Mo2 LLC
5% Or Greater Direct Ownership Interest · Organization
Berger, Eliot
Corporate Director · Individual
Blue Sky Basin LLC
5% Or Greater Indirect Ownership Interest · Organization
Dkdp Missouri LLC
5% Or Greater Indirect Ownership Interest · Organization
Dkyh Missouri LLC
5% Or Greater Indirect Ownership Interest · Organization
Dkyh Missouri LLC
General Partnership Interest · Organization
Kleiner, Dovid
Limited Partnership Interest · Individual
Perlow, Bernard
Corporate Director · Individual
Sloans Lake Trust
5% Or Greater Indirect Ownership Interest · Organization
Yocum, Tammy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oregon Care Center
Oregon, MO
1-star overall rating with 2-star inspections with abuse icon flag with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Falls City Nursing and Rehabilitation Center
Falls City, NE
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Nodaway Healthcare
Maryville, MO
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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