Your report for Carriage Square Rehab and Healthcare Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MissouriLowest tier among peers479 rated homes · average 2.5★
- Buchanan CountyLowest tier among peers6 rated homes · average 1.8★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs MO avg
- StaffingCan add or remove a star1★−1.1 vs MO avg
- Quality measuresCan add or remove a star2★−0.7 vs MO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMO avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersMO avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 19% of peersMO avg2.7★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.56hrsAbove 63% of peersMO avg3.47Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.38hrsAbove only 44% of peersMO avg0.46Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better68%Above only 24% of peersMO avg57%RN turnover87%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$48,685Above only 21% of peersMO avg$37,310Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthAug 2021 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 23, 2025Cycle 1worst E · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareE · patternCorrected Dec 24, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 24, 2025
Dec 3, 2025Cycle 1worst D · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 8, 2025
Nov 3, 2025Cycle 1worst E · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareE · patternCorrected Nov 24, 2025
Mar 14, 2025Cycle 1worst J · immediate jeopardy$48,685
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 17, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Apr 17, 2025
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Apr 17, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 17, 2025
- F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationF · widespreadCorrected Apr 17, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 17, 2025
- F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Apr 17, 2025
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Apr 17, 2025
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationF · widespreadCorrected Apr 17, 2025
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationF · widespreadCorrected Apr 17, 2025
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Apr 17, 2025
- F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Apr 17, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Mar 3, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Apr 17, 2025
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Apr 17, 2025
Apr 23, 2024Cycle 2worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 14, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 14, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 14, 2024
Jul 14, 2023Cycle 2worst F · no actual harm
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Sep 20, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Sep 20, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Sep 20, 2023
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsE · patternCorrected Sep 20, 2023
- F584Honor 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.Resident RightsE · patternCorrected Sep 20, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Sep 20, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Sep 20, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Sep 20, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Sep 20, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 20, 2023
- F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareE · patternCorrected Sep 20, 2023
- F727Have 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.Nursing and Physician ServicesE · patternCorrected Sep 20, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Sep 20, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 20, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Sep 20, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalF · widespreadCorrected Sep 20, 2023
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 20, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Sep 20, 2023
Mar 10, 2023Cycle 3worst E · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 4, 2023
- F761Ensure 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.Pharmacy ServiceE · patternCorrected May 4, 2023
Aug 5, 2021Cycle 3worst E · no actual harm
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 30, 2021
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Sep 30, 2021
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsD · isolatedCorrected Sep 30, 2021
- F584Honor 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.Resident RightsE · patternCorrected Sep 30, 2021
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 30, 2021
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Sep 30, 2021
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Sep 30, 2021
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Sep 30, 2021
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Sep 30, 2021
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Sep 30, 2021
- F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareD · isolatedCorrected Sep 30, 2021
- F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Sep 30, 2021
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 30, 2021
- F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and DietaryD · isolatedCorrected Sep 30, 2021
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Sep 30, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.56hrs
- Registered nursesRN hours only0.38hrs
- Licensed practical nursesLPN hours0.57hrs
- Nurse aidesCNA hours2.61hrs
- Weekend nursingAll staff on Saturdays and Sundays2.95hrs
- Missouri average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better68%Above only 24% of peersMO avg 57%
- RN turnoverRegistered nurses only87%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy130 certified beds · ~92 residents a day71%Above only 44% of peersMO avg 72%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $48,685In fines
- 1Fine
- 0Payment denials
- $37,310MO avg in fines
Actions on record
- Mar 14, 2025Civil money penalty$48,685
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Ama Holdings14 facilities in the chain1.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Mo Operation Holdings de Spe LLC
- Ama Holdings LLC
- Def Holdings LLC
- Asher Marx
- Jacques Wolf
- Mo Operation Holdings de Spe LLC
- Asher Marx
- Jacques Wolf
- Amy Byrom
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 265336 · 4009 GENE FIELD ROAD, SAINT JOSEPH, MO, 64506.
- Percentiles compare this facility with every rated nursing home in Missouri and Buchanan County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









