Beautiful Savior Home
1003 South Cedar Street, Belton, MO 64012 · For profit - Limited Liability company · 126 certified beds · (816) 331-0781 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.1% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.2% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.4% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.5% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.7% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.2% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.1% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.5% | 63.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.0% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.0% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.66 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.76 | 2.33 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 32.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 32.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 39.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 126 beds and averages 79.3 residents a day — about 63% occupied, or roughly 47 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.10 hrs/resident/day on weekends vs 3.58 on weekdays — 13% thinner on weekends. RN hours go from 0.38 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from abuse when on 5/7/26 Resident #2 forceable grabbed the resident's chin/jaw area causing discoloration and bruising out of 3 sampled residents. The facility census was 70 residents.On 5/15/26, the Administrator was notified of past non-compliance which occurred on 5/7/26. Immediate interventions were put in place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 5/8/26. Review of the facility's policy titled Abuse and Neglect-Clinical Protocol dated March 2018 showed:-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.-Willful was defined as used in the definition of abuse, meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent physical abuse for one sampled resident (Resident #2) out of five sampled residents. On 4//26/26 Resident #1 struck another Resident #2 in the face with his/her fist causing redness and bruising. The facility census was 72 residents.On 5/6/26, the Administrator was notified of past non-compliance which occurred on 4/26/26. Immediate interventions were put in place for both Resident #1 and Resident #2. All staff received education prior to working their next shift. The deficiency was corrected on 4/27/26. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, showed:-Residents had the right to be free from abuse.-The Abuse, Neglect, Exploitation and Misappropriation Prevention Program was a facility-wide commitment to support and protect residents from abuse by anyone, including other residents, and:-To establish and maintain a culture of compassion and caring for all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-12-13 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having an approved certification for food service management and safety from a certifying body, an associate's degree in food service management or hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. This practice potentially affected all residents. The facility census was 76 residents. Review of the facility's Dietitian policy, revised November, 2022 showed if a Dietitian is not employed full time (35 or more hours per week) a Director of Food and Nutrition Services will be designated. This individual will: -Be a certified dietary manager, a certified food services manager, or be nationally certified in food service management and safety, or -Have an associate degree or higher in food service management or hospitality if the course includes food service or restaurant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure condiments were stored properly, clean grease and food from condiment and spice containers, clean grease build up from kitchen surfaces including the stove and oven, remove build-up of soap or other substances from soap dispensers, a soap dish, and dish washing machine trays, and to ensure trays and food containers were not stored on surfaces that were chipped and therefore unable to be sanitized. This practice potentially affected all residents who ate food from the kitchen. The facility census was 76 residents. 1. Observation on 12/05/24 from 9:31 A.M. to 12:55 P.M. showed: -At 9:31 A.M. bits of debris were all over the kitchen floor, most of which were one-half inch and smaller, with a few bits larger. There were multiple spills on the floor. -The stove knobs, surface surrounding the knobs, and two oven handles of the stove (stove/griddle/oven appliance) had a build up grease. The six burners had a crusty charred built-up coating. The sides of the appliance had a light film of grease with adhering dust. The gas…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices for three sampled residents (Resident #58, #27, and #74) who was on Enhanced Barrier Precautions (EBP - refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove during high contact resident care activities) failed to use adequate hand hygiene during incontinence care for (Resident #58); failed to ensure infection control was maintained during wound care for one sampled resident(Resident #2); failed to perform proper hand hygiene during cares for one sampled resident (Resident #74); and failed to ensure yearly tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) test was completed for two sampled residents (Resident #32 and #2) out of 18 sampled residents. The Facility census was 76…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-13 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) staff were able to identify who was CPR certified staff on all shifts. The facility census was 76 residents. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised February 2018 showed: -Personnel have completed training on initiation of cardiopulmonary resuscitation and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. -The chances of surviving sudden cardiac arrest may be increased if CPR was initiated immediately upon collapse. -Select and identified a CPR team for each shift in the case of an actual cardiac arrest. -To the extend…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-13 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 76 residents. Review of the facility Antibiotic Stewardship policy, revised December 2023 showed: -Antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. -Instruction that physician's orders for antibiotics would include the drug name, dose, frequency of administration, duration of treatment, start and stop date or number of days of therapy, route of administration and the indications for use. -If a laboratory test was ordered, the results and the resident's current clinical situation would be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility Infection Prevention and Control Program policy, revised December 2023 showed: -Culture reports, sensitivity data and antibiotic usage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of one sampled resident (Resident #68) out of 18 sampled residents. The facility census was 76 residents. Review of facility policy Bath, Shower/Tub revised 2/2018 showed: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. -Document date and time the bath or shower was preformed. -Document the name and title of the individual(s) who assisted the resident with the shower/tub bath. -Document all assessment data (e.g., any reddened areas, sores, etc., on the residents skin) obtained during shower/tub bath. -Document if the resident refused the shower/tub bath, reason(s) why and the interventions taken. 1. Review of Resident #68's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure weekly wound tracking for one sampled resident (Resident #2) with a history of a chronic Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); and failed to ensure services to prevent and heal pressure ulcers for one sampled resident (Resident #58) who was at high risk for skin breakdown out of 18 sampled residents. The facility census was 76 residents. Review of the facility Wound Care Policy, revised 10/2010 showed: -The following documentation should be recorded in the resident's medical record: --The type of wound care given. --The date and time the wound care was given. --All assessment data (i.e., wound bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough fall investigation to include interviews of staff and/or potential witnesses, failed to complete fall assessments after each fall, and failed to implement appropriate interventions for a significantly cognitively impaired resident (Resident #32) out of 18 sampled residents. The facility census was 76 residents. Review of the facility policy Assessing Falls and Their Causes Revised 3/2018 showed: -When a resident falls, the following information should be recorded in the resident's medical record: --The condition of which the resident was found. --Assessment data, including vital signs and any obvious injuries. --Interventions, first aid, or treatment administered. --Notification of physician and family, as indicated. --Completion of a falls risk assessment. --Appropriate interventions taken to prevent future falls. -Define details of falls. -Identify causes of falls. -Perform a post-fall evaluation. 1. Review of Resident #32's face…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-12-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess a resident's Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) for proper placement for one sampled resident (Resident #74) out of 18 sampled residents. The facility census was 76 residents. Record review of the facility's Confirming Placement of Feeding Tubes policy revised November 2018 showed: -The exit site of the feeding tune would be marked (by incremental marking on the tube or by documented tube length) at initial time of placement. -If a change in the incremental length was observed, use additional method(s) to test whether the tube was properly positioned: --Observed for symptoms of elevated gastric residual volume (GRV): ---A sharp increase in residual volume might have indicated that a small bowl tube has migrated into the stomach. ---Little to no residual might have suggested the tube has migrated from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-05-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to remove a buildup of dust on the ceiling above the food preparation table; to remove a buildup of food debris and dust from under the six burner stove, the steam table and the food preparation table; to remove a heavy buildup of grease and burnt-on food from the metal grates that sit above the actual gas burners; and to maintain the gaskets (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of the reach-in refrigerator in good repair. This practice potentially affected all residents. The facility census was 87 residents. 1. Observations on 5/1/23 from 9:15 AM through 12:50 PM, showed: -A torn gasket on reach-in Fridge identified as RI, was torn on both doors of the reach in refrigerator. -A buildup of dust on the ceiling tiles on and on the smoke detectors above the food preparation table. -A buildup of debris under reach-in refrigerators, under the steam table and under the six - burner stove, including a plastic cup. -A heavy buildup of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-05 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding infection control monitoring and tracking of infections in the facility which potentially affected all residents in the facility. There were 19 residents in the sample and the facility census was 87 residents. Record review of the Infection Surveillance-Overview from the facility's Infection Prevention and Control Manual dated 2020 showed, -Data Analysis will assist the facility in: --Determining the origin of infection. --Comparing current and past infection control surveillance. --Comparing the reported incidence of infections by type and location. --Determining need for additional education and staff competency. --This data is recorded at least quarterly and included in the QAA committee for review and inclusion of QAPI activities. 1. During an interview on 5/4/23 at 12:46 P.M. the Infection Preventionist said: -Whatever Point Click Care (PCC- a web based electronic health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-05-05 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during incontinence care for one sampled resident (Resident #85); to ensure hand hygiene was completed during blood glucose monitoring, to ensure reusable devices were properly cleaned to prevent cross contamination, and to provide appropriate wound care for one sampled resident (Resident #88); to maintain an effective infection control program including tracking and trending of infections; and failed to ensure residents who admitted to the facility had Tuberculosis (TB- an infectious bacterial disease characterized by the growth of nodules in the tissues, especially the lungs) testing completed and up to date for four sampled residents (Residents #75, #73, #70, and #27) on admission out of 19 sampled residents. The facility census was 87 residents. Record review of the facility's Handwashing policy and procedure dated 4/09, showed: -Hand hygiene is a basic procedure that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-05-05 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a process to monitor antibiotic usage including prescribing and documentation of the indication, dosage, and duration of the use of antibiotics. This failure had the potential to affect all residents at the facility. The facility census was 87 residents. Record review of the facility policy titled Antibiotic Stewardship Program Policy dated 6/3/21 showed: -The facility was to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. -Antibiotic stewardship actions were conducted to enable or to measure these key elements of care: --Knowing when to be concerned about an infection in a resident. --What clinical and historical information to gather for the provider. --When to submit diagnostic specimens to the laboratory. --How to quantify and assess appropriateness of antibiotics prescribed. --How to identify adverse outcomes that might be associated with antibiotics. -The actions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-05 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure privacy and dignity was preserved during incontinence care for two sampled residents (Resident #85, and #20) and one supplemental resident (Resident #66) out of 19 sampled residents and five supplemental residents. The facility census was 87 residents. Record review of the facility's undated Notice of Resident Privacy/Dignity Practices showed: -Dignity refers to treating residents with respect. Examples include respecting the resident's wishes, responding to their need and treating them as individuals. -Dignity also means respecting their rights, giving them freedom of choice .providing them privacy and their own personal space. -For those with cognitive impairments, it is important that the preferences they had are still acknowledged even though they may no longer be able to express their preferences. 1. Record review of Resident #85's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the ceiling vents in the shower rooms of 100 Hall, 200 Hall and the 500 Hall, free of a heavy buildup of dust; and to maintain the base of a standup lift (a medical device that assists individuals with limited mobility in standing up from a seated position. This type of lift is designed for individuals who find it difficult or impossible to stand up without assistance due to a variety of medical conditions or disabilities) without a two inch (in.) crack. This practice potentially affected at least 60 residents who may obtain their showers in the facility shower rooms and seven residents who needed the assistance of a stand-up lift. The facility census was 87 residents. 1. Observation with Maintenance Assistant A on 5/2/23, showed: -At 1:30 P.M., there was a buildup of dust in the restroom ceiling vent in resident room [ROOM NUMBER]. -At 1:44 P.M., there was a heavy buildup of dust in the ceiling vents in the 100 Hall shower room ceiling vent.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident safety while on the toilet that resulted in a fall with injury for one sampled resident (Resident #27) out of 18 sampled residents. The facility also failed to maintain hot water temperatures in resident rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 4101, 402, 403, 405, 406, 407, 408, 409, 502 and 504 below 120 ºF (degrees Fahrenheit) on 5/1/23. This practice potentially affected 33 residents who resided in resident rooms served by Nurse's Station 2. The facility census was 87 residents. Record review of the facility's undated Fall policy and procedure showed it is the policy of the facility to aggressively work to prevent resident falls by promoting a safe environment, by assessing possible causal factors which can lead to falls and to train staff, residents, and families on fall prevention. The policy showed: -Following any falls the staff will complete an occurrence report (fall report). Details…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store oxygen face masks, tubing, nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), in a plastic bag to prevent cross-contamination when not in use for one sampled resident (Resident #5) and one supplemental resident (Resident #49); to store a bi-level positive airway pressure (bi-pap a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) mask in a plastic bag for one supplemental resident (Resident #48); to store a nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) mask in a plastic bag for two supplemental residents (Resident #12 and #21) out of 19 sampled residents and five supplemental residents. The facility census was 87 residents. Record review of the facility undated Oxygen storage Policy showed: -Oxygen tubing, nasal cannula and masks are to be changed weekly. The tubing must be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the correct dosage of Insulin(a hormone used to treat high blood sugar) was administered by not priming the insulin pen (an injection device with a needle that delivers insulin into the tissue) before administering insulin to one sampled resident (Resident #88) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility's undated policy titled Procedure for Insulin Administration using Insulin Pen showed: -Once a new needle was attached, staff were to set the pen's dial to 2 units, hold the pen vertically with the tip facing the ceiling, and press the dose button. -Staff were to visualize a drop or stream of insulin at the tip of the needle to ensure all air had been removed. -If a drop or stream of insulin was not seen at the tip of the needle, staff were to repeat the process. 1. Record review of Resident #88's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 2/20/23, showed the resident:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained by placing an indwelling catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that held drained urine) at or above the level of the bladder during wound care for one sampled resident (Resident #2) and by not providing catheter care and not obtaining a physician's order for an indwelling catheter for one sampled resident (Resident #88), who were both at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility Catheter Care policy dated 6/13/22 showed: -The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower than the bladder to allow drainage by gravity. -The facility staff were required to provide catheter care for indwelling catheters at least twice a day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-06-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by the off-going and on-coming nursing staff per the facility policy. The facility census was 80 residents. Record review of the facility's undated Medications-Narcotics policy showed: -Narcotics should be counted at the beginning and end of every shift by the unit charge nurse or Certified Medication Technician(CMT). -Both nurses or CMTs should date and sign the count log in the cart's narcotic notebook. -The Director of Nursing (DON) should be notified immediately if there were any discrepancy in the narcotics count. -If the unit charge nurse or CMT had to leave before the end of a shift, he/she should count the narcotics with the oncoming charge nurse or CMT before he/she left the facility. The charge nurse/CMT would then count with the charge nurse or CMT from the oncoming shift. Record review of a facility Narcotic Shift Change Count Sheet showed staff were to document the date, shift, on-coming shift signature, off-going shift signature, number of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SHAFIQ MALIK — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 3.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 3 of 5 | 2.4 | +0.6 vs chain |
The other 8 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BLEAURIDGE NURSING AND REHAB LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 08/30/2024 |
| HAAS, BRIAN | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | — | since 04/02/2025 |
| FORVIS MAZARS LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/30/2024 |
| MALIK, OMER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/18/2024 |
| MALIK, SHAFIQ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/30/2024 |
| SMITH, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/30/2024 |
CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265782. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.