312 Solley Drive, Ballwin, MO 63021 · St. Louis County · (636) 391-0666
137 certified beds, about 87 residents a day · For profit - Corporation · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 265352 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 23, 2025, inspectors cited 11 health deficiencies (the Missouri average is 11.4, the national average 9.2).
Of 53 health citations since February 2020, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $197,132 in the last three years; the largest was $197,132, and the latest is dated May 23, 2025.
Nurses and nurse aides worked 3.23 hours per resident per day, against 3.43 across Missouri and 3.86 nationally. Registered nurses accounted for 0.40 of those hours.
CMS links it to Ama Holdings, an affiliated group of 13 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 53 health citations on file.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received adequate supervision and interventions to ensure their safety. Resident #131 admitted on [DATE] from the hospital with altered mental status suspecting underlying dementia with psych issue, and in need of a secure unit. On 4/11/25, the resident left through an alarmed exit door on the secured memory care unit. The alarm sounded on the exit door, however, staff did not visually verify the location of residents on the unit. On 4/19/25, Resident #131 smashed a window with a toilet tank lid, cried and said he/she wanted to leave and threatened to jump out the window. He/She was hospitalized for two days and returned on 4/21/25 with a diagnosis of severe urinary tract infection (UTI). [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a safe, homelike environment by failing to ensure residents and staff had access to clean towels for three sampled residents (Resident #34, #36 and #58). Staff also failed to ensure one resident's broken window was fixed (Resident #15), failed to ensure three resident's personal refrigerators had completed temperature logs (Resident #4, #8 and #23) and failed to maintain the hot water at the minimum required temperature of 105 degrees Fahrenheit (F) for three residents (Resident #36, #23 and #55). In addition, staff failed keep the hallway on the Memory Care Unit free from trash. The sample was 19. The census was 74. Review of the facility's housekeeping policy, dated 10/24/22, showed: -Purpose: [...]
Inspectors wroteBased on interview and record review, the facility failed to complete criminal background checks in accordance with their policy on newly hired or transferred employees, prior to the employee's start date, and failed to ensure the employees were screened to rule out the presence of a Federal Indicator through the Nurse Aide (NA) Registry, for three of 10 employees hired since the last survey. In addition, the facility's policy for screening new hires failed to include completion of checking the NA Registry. The census was 74. Review of the facility's Abuse Prevention and Prohibition Program policy, revised 10/24/22, showed: -Purpose: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents that required assistance with activities of daily living (ADLs- bathing, dressing and toileting) received necessary services to maintain adequate personal hygiene when staff left three residents soiled for an extended period (Resident's #67, #65 and #17). The facility staff did not provide showers to two residents (Resident #17 and Resident #29). The sample size was 19. The census was 74. Review of the facility's Care and Services policy, revised 10/22/24, showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term facility; -Care and Services are provided in a manner that consistently enhances self-esteem and worth. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and solutions kept in the facility's medication rooms and on medication carts were not expired. In addition, the facility failed to ensure temperature logs in the facility's medication rooms were completed. The sample was 19. The census was 74. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. [...]
Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a palatable, safe and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F). This affected five of 19 sampled residents (Residents #17, #36, #38, #50 and #55). The census was 74. Review of the facility's food temperature policy, dated 10/24/22, showed: -Policy: foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Procedure: if temperatures do not meet the required serving temperatures, reheat the product or chill the product to the proper temperature. -Acceptable food temperatures: meat should be greater than 135 degrees F, potatoes should be greater than 135 degrees F. 1. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received an accurate assessment reflective of resident status at the time of assessment by coding side rails as restraints on the Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, for three residents who were determined to use side rails without restriction of freedom of movement (Residents #50, #23, and #20). The sample was 19. The census was 74. Review of the facility's Resident Assessment Instrument (RAI) Process policy, showed: Purpose: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to obtain treatment orders for a dressing to the resident's left leg, apply compression stockings to his/her legs, and complete an accurate assessment of the resident's edematous (swollen with excess fluid) legs (Resident # 27). In addition, the facility failed to perform a post-fall neurological assessment (an assessment that checks the resident's mental status, level of consciousness, pupil reaction, motor (movement) response to stimulation, and sensation) on two residents (Resident #27 and #15). The sample size was 19. The census was 74. Review of the facility's Care and Services policy, revised 10/22/24, showed: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bipap (a form of non-invasive ventilation therapy) masks were properly stored for two residents (Residents #17 and #55) and failed to ensure the oxygen concentrator (medical device that separates nitrogen from the air) was set to the proper rate for one resident (Resident #55). The sample was 19. The census was 74. Review of the facility's oxygen administration policy, dated 10/24/22, showed: -Policy: a physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: oxygen flow rate, method of administration (e.g. nasal cannula (NC)), usage of therapy (continuous or as needed (PRN)), titration instructions (if indicated), and indication for use. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one resident (Resident #63). The facility identified one resident receiving dialysis. The sample was 19. The census was 74. Review of the facility's Dialysis Care policy, revised 10/24/22, showed: -Purpose: To provide are for residents diagnosed with renal disease requiring ongoing dialysis treatments; -Policy: --The facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all nondialysis needs of the resident including during the time period when the resident is receiving dialysis; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain laboratory services as ordered by the physician for one resident (Resident #65). The sample was 19. The census was 74. Review of the facility's Laboratory, Diagnostic and Radiology Services policy, revised on 10/24/22, showed: -Purpose: To ensure that laboratory, diagnostic and radiology services are provided to meet resident needs; -Policy: Laboratory, Diagnostic and Radiology services will be coordinated pursuant to an order by physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with the scope of practice under state law; The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible by failing to properly secure the resident's wheelchair to all of the locking mechanisms used to hold the resident's wheelchair in place during transport to another facility (Resident #1). This failure resulted in the wheelchair to fall/flip over backwards during a turn with the resident still in his/her wheelchair. The resident sustained a small gash in the back of his/her head which required first aid to stop the bleeding. The census was 53. The Administrator was notified on [DATE], of the past non-compliance. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were met, when the facility admitted a resident without physician's orders and failed to provide prescribed medications that evening. The resident was sent to a different hospital, 14 hours later, without physician's orders (Resident #1). The facility did not have a policy for obtaining physician orders at the time of admission. The sample was 3. The census was 49. Review of the resident's hospital discharge summary and discharge instructions, received via email from the facility Administrator on 9/18/24 at 5:11 P.M., with a printed time and date stamp of 8/21/24 at 2:03 P.M. central daylight time (CDT), showed: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be safe during a transfer when a staff member transferred the resident without a using a Hoyer lift (a mechanical device to assist with transferring) and/or without additional staff assistance, and against the facility's policy, which resulted in the resident sustaining a fractured leg (Resident #20). The facility also failed to ensure all nursing staff had access to residents' electronic medical records through Point Click Care (PCC) prior to working with residents. This prevented staff from having access to care plans and/or Kardex (filing system used as a quick reference for staff) information. The facility failed to inservice staff and update care plans with the most current information regarding resident care needs. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADLs, personal care) received showers in accordance with their needs and preferences (Residents #4, #5, #7, #11 and #2). The sample was 11. The census was 44. Review of the facility's Skin Monitoring: Comprehensive Shower Review Sheet, showed: -Perform a visual assessment of a resident's skin while giving them a shower; -Report any abnormal looking skin (as described below) to the charge nurse immediately; -Forward any problems to the Director of Nursing (DON) for review; -Use the form to show exact location and description of the abnormality, using the body chart: -Describe and graph all abnormalities by number; -A space designated for residents' name and date; -A numerical listing from 1 to 14 for examples of visual assessment; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 42 opportunities, 4 errors occurred, resulting in an 9.52% error rate (Residents #4 and #5). The census was 44. Review of the facility's Medication policy dated 10/24/22, showed: Procedure: Nursing Staff will keep in mind the seven rights of medication when administering medication: -The right medication; -The right amount; -The right resident; -The right time; -The right route; -Right indication; -Right outcome; -Additional considerations include: The Rule of 3. The Licensed Nurse administering medications will perform three checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR): -Compare the Licensed Practitioner's prescription/order with the MAR (first check); [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurately documented clinical records regarding pressure ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction) for one of 11 sampled residents (Resident #2). The census was 44. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/24, showed the following: -admission date 4/7/24; -Cognitively intact; -Able to make self-understood; -Rejection of care 1-3 days per week; -Dependent on staff for transfers, locomotion, personal hygiene and bathing; -admitted with one Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. [...]
Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not thoroughly investigating an allegation of a resident being hit in the head by a male nurse. The facility failed to interview the resident and the resident's sibling who reported the allegation to the facility's Marketing Director while he/she was visiting the resident in the hospital (Resident #1). The sample was three. The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of resident abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for one of three sampled residents (Resident #1). The census was 45. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed the following: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -1. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two residents who expired and had money in their accounts (Residents #301 and #302). The sample size was 15. The census was 43. Review of Resident #301's medical record, showed: -discharged on [DATE] and expired on [DATE]; -On [DATE], an ending balance of $4554.33; -No documentation of TPL completed. Review of Resident #302's medical record, showed: -discharged to the hospital on [DATE]; -On [DATE], an ending balance of $4194.75; -No documentation of TPL completed. During an interview on [DATE] at 11:59 A.M., the Business Office Manager (BOM) confirmed Resident #302 expired in September after he/she was sent to the hospital. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of four residents (Residents #198, #11, #13 and #24). The sample was 15. The census was 43. Review of the facility's Care Plan policy, revised 6/2020, showed: -Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs; -Procedure: The Facility will develop a person-centered baseline care plan for each resident within 48 hours of admission. The baseline care plan will include at least the following information: Initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A comprehensive person-centered care plan will be developed for each resident. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure services provided met professional standards of practice when one nurse prepared medications in a cup and handed the cup to another nurse to administer for three residents (Residents #33, #36 and #7). Staff also failed to complete post fall documentation for one resident (Resident #145). The sample was 15. The census was 43. Review of the facility's Medication Administration Policy, dated 10/24/22, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; -Documentation: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to provide adequate organized activities in the evenings and on the weekends. The resident council representatives reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program, including one on one activities (Residents #24, #37, #28 and #20). The sample size was 15. The census was 43. Review of the facility's Activities Program Policy, dated 6/20, and showed: -Purpose: [...]
Inspectors wroteBased on interview and record review, the facility failed to staff the facility with a Registered Nurse (RN) at least eight hours a day, seven days a week. The census was 43. Review of the facility's schedules, dated 10/29/23 through 11/29/23, showed on the following days no RN was scheduled on 10/29, 10/30, 11/3, 11/5, 11/6, 11/10, 11/17, 11/18, 11/19, 11/24, 11/25, 11/26 and 11/27. Review of the timecard sheets, showed: 10/29: no RN hours; 10/30: less than 8 hours of RN coverage documented; 11/3: less than 8 hours of RN coverage documented; 11/5 through 11/6: no RN hours; 11/10: less than 8 hours of RN coverage documented; 11/17: less than 8 hours of RN coverage documented; 11/18 through 11/20: no RN hours; 11/24: less than 8 hours of RN coverage documented; 11/25 through 11/27: no RN hours. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified four medication/treatment carts and one medication room. There was one medication cart for each of three halls and one medication cart used only by nurses. Three of the four carts and one medication room were checked for medication storage, and issues were found in the medication room and in the nurse medication cart. Staff failed to keep the medication room door locked at all times, separate the medications and food storage in the medication room refrigerators, date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution, and to place two locks on the substance controlled medication storage. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were afforded the right to a dignified existence, self-determination, and communication with persons and services inside the facility. One of 15 residents sampled during the survey period was observed calling out loudly for assistance or attention while staff walked by the resident's room. The census was 47. Review of Resident #37's medical record, showed his/her diagnoses included anoxic brain damage (damage to the brain caused by a temporary lack of oxygen), pulmonary embolism (a blood clot in the lungs affecting a patient's ability to breathe), gastrostomy (a surgical opening into the abdomen for the introduction of nutrition), and Type 2 Diabetes. Review of the resident's care plan, in use at the time of survey, showed: -Focus: [...]
Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #34 and #246). The sample size was 13. The census was 43. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]
Inspectors wroteBased on interview and record review, the facility failed to follow their own Grievance and Complaints Policy when staff failed to follow up and document one resident's (Resident #145) grievance for an allegation of missing items. The sample was 15. The census was 43. Review of the facility's Grievances and Complaints Policy, dated 10/24/22, showed: -Purpose: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints; - Any resident, representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property, etc., without fear of threat or reprisal in any form; - Grievances and/or complaints may be submitted orally or in writing and can be made anonymously through the compliance hotline; -Designation of Grievance Official: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene for two residents observed with long, dirty fingernails and food/beverages on clothing (Residents #24 and #246). The sample size was 15. The census was 43. Review of the facility's Activities of Daily Living (ADL), Supporting, policy, revised March, 2018, showed: -Policy Statement; -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Policy Interpretation and Implementation; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, two errors occurred resulting in a 7.69% error rate (Residents #16). The census was 43. Review of the facility's Medication Administration Policy, dated 10/24/22, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Medications will not be left at the bedside. Review of mybrevo.com, showed: -Breo Ellipta, Breo is a prescription medicine used long term to treat: Chronic Obstructive Pulmonary Disease (COPD, chronic lung disease) and asthma: -Patient instructions: Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water; -Warning and Precautions: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication errors when the facility failed to administer ordered medications for two days after admission for one resident (Resident #198). The sample size was 15. The census was 43. Review of the facility's Medication Administration policy, revised October 24, 2022, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: -Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law; -No medication will be used for any resident other than the resident for whom it was prescribed; -Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; [...]
Inspectors wroteBased on observation and interview the facility failed to make available the most recent surveys and any abbreviated survey results, in a place that was readily accessible to residents, family members and legal representatives of the residents. The census was 43. Observations on all days of the survey from 11/29/23 through 12/1/23 and 12/4/23, showed the main entrance to the building was locked with a sign asking visitors to use the 900 hall entrance. On the other side of the lobby, a set of fire doors leading to the resident living areas were closed. The entire area from the main entrance to the fire doors was under construction. The Administrator's office was located off the main entrance, with a table outside the office. Various items were observed on the table. [...]
Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges for 24 residents, including Resident #21. The sample size was 15. The census was 43. Review of the facility's Transfer and Discharge Policy, dated revised 10/24/22, showed: -Purpose: To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider; -The facility may transfer or discharge a resident for the following reasons: -The transfer or discharge is: necessary for the resident's welfare and the resident's needs cannot be met in the facility; [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure five of five randomly selected Certified Nurses Assistants (CNAs), employed for one year or longer, received the required annual 12 hour in-services. The census was 60. Review of the CNA individual in-service records, showed the following: -CNA G, date of hire 8/30/11, with total number of hours zero; -CNA H, date of hire 11/18/16, with total number of hours zero; -CNA I, date of hire 6/27/18, with total number of hours zero; -CNA J, date of hire 10/16/12, with total number of hours zero; -CNA K, date of hire 1/7/19, with total number of hours zero. During an interview on 2/21/20 at 7:40 A.M. and 8:20 A.M., the administrator said it was the prior Director of Nurses (DON) responsibility to track and ensure CNAs received their 12 hours of continued educational in-service training. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated at least annually. The census was 60. Review of the Facility Assessment, showed the following: -Facility assessment dated [DATE]; -No further review and/or update of the Facility Assessment annually as required. During an interview on 2/21/20 at 7:40 A.M., the administrator verified the Facility Assessment had not reviewed and/or updated annually since 11/13/17. The administrator said he is responsible for ensuring the Facility Assessment is reviewed and updated annually.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents' code status forms were updated annually, ensure code status forms were legible and ensure the code status forms matched the code status listed on the physician's order sheets for four of 15 sampled residents (Resident #3, #7, #105 and #24). The census was 60. 1. Review of Resident #3's medical record, showed the following: -An admission face sheet, showed an admission date of 10/22/18; -A signed code status form, dated 2/15/19, for do not resuscitate (DNR, no life prolonging methods are performed); -A physician's order sheet (POS), dated 1/29/20 through 2/28/20, showed an undated order for full code status (all lifesaving methods are performed). Further review of the resident's medical record, showed no other updated code status forms regarding DNR and/or full code status. 2. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician's orders were followed and care met professional standards of quality, by not providing bone stimulation therapy, blood sugar checks, obtaining monthly, admission, or weights recommended by the registered dietician (RD), administering oxygen, monitoring a fluid restriction, reporting x-ray results in a timely manner, obtaining orders for hospice care and not documenting a resident's death for 14 (Resident #24, #18, #307, #3, #40, #45, #32, #27, #26, #7, #154, #28, #44 and #106) of 15 sampled residents, one expanded (#104) sampled resident and one closed (#54) record. The census was 60. 1. Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/19, showed the following: -No cognitive impairment; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received a minimum of two showers and failed to ensure the fingernails of two residents were kept trimmed. Of the 15 residents sampled, problems were found with four (Residents #27, #32, #45 and #28). The census was 60. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal care; -Diagnoses included heart disease and Alzheimer's disease. Review of the care plan, dated 8/2/13 and last updated on 12/12/19, showed the following: -Problem: Resident requires total care with all activities of daily living (ADLs) due to dementia. All needs must be anticipated by staff; -Goal: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents that qualified for restorative therapy services received those services as ordered for three of 15 sampled residents (Residents #3, #32 and #45). The census was 60. 1. Review of Resident #3's medical record, showed the following: -An admission face sheet showed an admission date of 10/22/18; -Diagnoses included history of falls and osteoarthritis (chronic degeneration of the joint cartilage). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Intact cognition; -Required supervision with bed mobility and transfers; -Required extensive assistance from staff with toilet use, hygiene and bathing; -No limited range of motion affecting upper/lower extremities; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess a resident's falls and follow their policy for fall management for one resident (Resident #44). The resident's fall resulted in an injury which required hospitalization. The facility also failed to protect three residents (Resident #18, #45 and #154) out of four observations from potential harm by not following their training guidelines or the manufacturer's recommendation for a Hoyer lift (mechanical device used to transfer a resident from one surface to another) transfer. In addition, the facility failed to protect residents from potential harm by not securing dangerous chemicals and razors on the secured unit, which had the potential to affect all ambulatory residents on that unit. The sample size was 15. The expanded sample size was nine. The census was 60. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with a history of urinary tract infections (UTIs), received appropriate treatment and services for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Additionally, the facility failed to obtain orders for the use, care and changing of catheters for three residents. The facility identified three residents as having a urinary catheter. All three were chosen, one for the initial sample (Resident #28) of 15 and two (Residents #42 and #255) for the expanded sample. Problems were found with all three. The census was 60. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/19, showed the following: -No cognitive impairment; [...]
Inspectors wroteBased on observation and interview, the facility failed to post and ensure the daily nurse staffing information contained the required information by not including the name of the facility, daily census and number of actual or total hours for each licensed and non-licensed nursing staff that were directly responsible for resident care for four of five days of observation. The census was 60. Observation on 2/19/20 at 1:10 P.M., 3:00 P.M. and 6:00 P.M., showed the facility's nurse staffing information posted on the board next to the employees' time clock in the main dining room, included the date and number of licensed and non-licensed nursing staff for each shift, but did not contain the name of the facility, daily census and actual/total hours worked for each nursing staff. Observation on 2/20/20 at 7:00 A.M. and 9:45 A.M., 2/21/20 at 6:00 A.M., 7:30 A.M. and 12:00 P.M. and 2/24/20 at 6: [...]
Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three narcotic books reviewed. The census was 60. Review of the facility's controlled substance policy, revised 1/2017, showed the following: -The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the oncoming licensed nurse and the off- going licensed nurse. Both nurses will sign on the narcotic sign in and out sheet that the count was completed. 1. Review of the west nurse's cart on 2/20/20 at 8:50 A.M., showed a controlled substances shift change count sheet dated, February 2020, which contained the following information: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician documented timely in the resident's medical record that any irregularities identified during the monthly medication regimen review (MRR) had been reviewed and what, if any, action had been taken to address it, and failed to have all MRRs documented, for 10 of 15 sampled residents(Residents #27, #32, #40, #45, #3, #7, #28, #24, #34 and #18). The census was 60. 1. Review of Resident #27's medical record, showed the following: -admitted to the facility on [DATE]; -Diagnoses included heart disease and Alzheimer's disease; -Pharmacy MRR completed on 1/7/20, with noted irregularities; -No documentation in the record if the physician reviewed the identified irregularities and if action had been taken. 2. Review of Resident #32's medical record, showed the following: -admitted to the facility on [DATE]; [...]
Inspectors wroteBased on observation and interview, the facility failed to keep the floors in the kitchen free from food crumbs, debris, and stains and sufficiently air dry dishes before use during three of three days of observation. The census was 60. 1. Observations of the kitchen on 2/19/20 at 10:57 A.M. and 3:55 P.M., 2/20/20 at 12:55 P.M., and 2/21/20 at 7:05 A.M. and 12:00 P.M., showed the following: - The floor tiles and grout throughout the kitchen noticeably dirty with food crumbs, dirt and debris; -Cracked tile under the drying rack parallel to the dish machine with a build up of crumbs and debris; -The perimeter of the grease trap with gaps between the tiles and the lid, with a build up that measured 1 inch to 3 inches, with a thick build up of crumbs and debris. During an interview on 2/21/20 at approximately 1:15 P.M., the dietary manager (DM) said she was aware of the status of the floors. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide information for 10 of 15 sampled residents (Resident #27, #32, #34, #40, #45, #3, #7, #106, #18 and #307) to show they received a yearly Tuberculin Skin Test (TST) to determine the presence of Tuberculosis (TB) or a yearly screening based on signs and symptoms of the disease. Furthermore, the facility failed to provide a second step TST to new employees as per their policy. The census was 60. Review of the facility's Infection Prevention and Control Manual TB Control Plan, dated 2019, showed the following: -Residents in long term care facilities have been identified as a high-risk group for re-activation of latent TB infection, acquisition of TB infection and potential spread of TB within the facility. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident remained free from restraints, conduct a restraint assessment and obtain a physician's order for the use of a restraint (Resident #45). The facility identified no residents with restraints. The sample size was 15. The census was 60. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/20, showed the following: -No cognitive impairment; -Dependent on staff for all mobility and personal care; [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were updated to reflect the residents' current needs by not including services and care provided by hospice providers, in collaboration with the facility, for three residents (Residents #106, #54 and #34). The facility identified seven residents who received hospice care. Three were chosen for the sample of 15, and problems were found with all three of them. The census was 60. 1. Review of Resident #106's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admission date [DATE]; -Intact cognition; -Diagnoses included anemia (decrease in the number of red blood cells) and respiratory failure; -Required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents individualized activities, designed to meet the residents' interests and support the physical, mental, and psychological well-being of each resident for two of 15 sampled residents (Residents #307 and #32). The census was 60. 1. Review of Resident #307's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/11/20, showed the following: -admitted [DATE]; -Activity preferences: Listening to music, going outside in good weather and doing favorite activities; -Brief interview for mental status (BIMS) score 10 out of 15; cognition moderately impaired. Review of the resident's medial record, showed the following: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with a wound (Resident #154) of 15 sampled residents, received the appropriate treatment and care, by not treating the wound for multiple days, following a readmission to the facility and after a new order was received from the wound care provider. The census was 60. Review of Resident #154's face sheet, showed the following: -Initial admission to facility on 1/27/20; -readmitted on [DATE]; -Diagnoses included heart failure, chronic kidney disease, obesity, high blood pressure, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and cellulitis (skin infection). Review of the resident's treatment administration record (TAR), showed weekly skin assessments on Tuesdays, left blank on 2/4/20 and 2/18/20, with no documentation on the back of the TAR. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received appropriate assessment and necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for two of 15 sampled residents (Resident #154 and #28). The census was 60. 1. Review of Resident #154's face sheet, showed the following: -Initial admission to facility on 1/27/20; -readmitted on [DATE]; -Diagnoses included heart failure, chronic kidney disease, obesity, high blood pressure, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and cellulitis (skin infection). Review of the resident's treatment administration record (TAR), showed weekly skin assessments on Tuesdays, left blank on 2/4/20 and 2/18/20, with no documentation on the back of the TAR. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychiatric medications were re-evaluated after 14 days of use for one of five residents reviewed for unnecessary psychotropic medications (Resident #18). The sample was 15. The census was 60. Review of Resident #18 medical record, showed the following: -Diagnoses included dementia and anxiety; -Cognitively intact. Review of the resident's physician order sheets (POS), dated 1/29/20 through 2/28/20, showed the following: -An order, dated 12/2/19, for alprazolam (Xanax, used to treat anxiety) 0.25 milligrams (mg), take twice daily as needed; -No end date noted for the PRN order. Review a pharmacy medication regimen review, to determine if resident had been using the PRN alprazolam dated 1/6/20, showed, If resident has not used it within the past 14 days, please clarify. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two random sampled residents (Resident #31 and #12) and one sampled resident (#307) remained free from significant medication errors regarding insulin not administered as ordered. The sample was 15. The census was 60. 1. Review of Resident #31's medical record, showed the following: -An admission date of 2/28/19; -Diagnoses included diabetes. Review of the resident's physicians order sheet (POS), dated 1/29/20 through 2/28/20, showed the following: -An order dated 2/28/19, to administer Novolog (fast acting) insulin, 18 units subcutaneous (SQ, beneath the skin) three times daily (TID) (scheduled administration time 7:30 A.M., 11:30 A.M. and 4:30 P.M.); [...]
30 fire safety citations on file: 11 on May 23, 2025, 12 on December 5, 2023, 7 on February 25, 2020.
| Date | Penalty | Amount or length |
|---|---|---|
| May 23, 2025 | Fine | $197,132 |
| May 23, 2025 | Payment Denial | 12 days from June 28, 2025 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Missouri | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.23 | 3.43 | 3.86 |
| Registered nurses | 0.40 | 0.46 | 0.69 |
| All nursing staff on weekends | 2.90 | 3.01 | 3.42 |
| Nurse aides | 2.36 | ||
| Licensed practical nurses | 0.47 | ||
| Nursing staff turnover (share who left in a year) | not reported | 56.0% | 45.8% |
| Registered nurse turnover | not reported | 47.8% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.90 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.37 on weekdays and 2.90 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 7.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.57 in April to June 2025 to 3.23 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.23 | 0.40 | 3.37 | 2.90 | 7.0% | 0 of 90 | 87 |
| Oct to Dec 2025 | 3.37 | 0.36 | 3.53 | 2.97 | 0.7% | 0 of 92 | 79 |
| Jul to Sep 2025 | 3.45 | 0.47 | 3.64 | 2.97 | 6.7% | 0 of 92 | 79 |
| Apr to Jun 2025 | 3.57 | 0.32 | 3.77 | 3.07 | 12.3% | 0 of 91 | 75 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Missouri, Jan to Mar 2026 | 3.34 | 0.40 | 3.50 | 2.93 | 3.9% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Missouri, all employers | |||
| CNAs (nursing assistants) | $18.11 | $17.02 to $20.00 | 34,050 |
| LPNs and LVNs | $29.58 | $27.06 to $33.77 | 14,700 |
| Registered nurses | $39.32 | $36.56 to $47.39 | 76,310 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Missouri | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.0 | 18.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.6 | 1.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.5 | 2.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.4 | 4.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.0 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.8 | 17.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.1 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.3 | 23.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 35.9 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.4 | 13.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.1 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 2.3 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Manchester Rehab and Healthcare Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Missouri: 41 better, 31 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 23 eligible stays.
12.0% this home
No different from the national rate
US median of homes 10.7% · Missouri: 0 better, 7 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 46 eligible stays.
8.1% this home
No different from the national rate
US median of homes 7.1% · Missouri: 1 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 29 eligible stays.
22.6% this home
Median of homes: Missouri51.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 31 residents counted.
0.0% this home
Median of homes: Missouri0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 66 residents counted.
3.1% this home
Median of homes: Missouri2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 66 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Missouri100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 8 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: MANCHESTER OPERATOR LLC. CMS links this home to Ama Holdings, a group of 13 nursing homes averaging 1.6 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Manchester Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 05/24/2023 |
| Ama Holdings LLC | 5% or greater indirect ownership interest | Organization | 05/24/2023 | |
| Andrew Capital LLC | 5% or greater indirect ownership interest | Organization | 05/24/2023 | |
| Def Holdings LLC | 5% or greater indirect ownership interest | Organization | 05/24/2023 | |
| Manchester Partners LLC | 5% or greater indirect ownership interest | Organization | 05/24/2023 | |
| Mo Operation Equities LLC | 5% or greater indirect ownership interest | Organization | 05/24/2023 | |
| Andrew, David | 5% or greater indirect ownership interest | Individual | 05/24/2023 | |
| Marx, Asher | 5% or greater indirect ownership interest | Individual | 05/24/2023 | |
| Wolf, Jacques | 5% or greater indirect ownership interest | Individual | 05/24/2023 | |
| Andrew, David | W-2 managing employee | Individual | 05/24/2023 | |
| Carosone, Rachel | W-2 managing employee | Individual | 08/14/2023 | |
| Marx, Asher | Corporate director | Individual | 05/24/2023 | |
| Wolf, Jacques | Corporate director | Individual | 05/24/2023 | |
| Marx, Asher | Operational/managerial control | Individual | 05/24/2023 | |
| Wolf, Jacques | Operational/managerial control | Individual | 05/24/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Missouri. NursingHomeClear cannot take or act on complaints.