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Rock Point Nursing Center

8477 North Street, Birch Tree, MO 65438 · For profit - Corporation · 86 certified beds · (573) 292-3212 Medicare & Medicaid certified

Call the home — (573) 292-3212 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Mar 2026Resident-funds citation (F0569)Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 24% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
9104 State Highway Highland Park Ste 100 · (417) 573-4237 · Call to confirm hours
Pharmacy
8499 Ash Ave · (573) 325-4241 · Call to confirm hours
Grocery
8953 Frisco St · (573) 292-3203 · Call to confirm hours
Park
4135 Eagle Ln · (417) 247-0250 · Typically dawn to dusk
Place of worship
108 MO-99 · (573) 292-3324

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 2 of 5
Long-stay residentspeople who live here 2 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 4 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.3%18.1%15.4%better
Long-stay residents who lose too much weight6.5%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%1.1%0.9%better
Long-stay residents with a urinary tract infection5.6%2.3%2.0%worse
Long-stay residents with depressive symptoms3.0%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%4.1%3.3%better
Long-stay residents whose ability to walk worsened7.5%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.4%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.6%90.9%95.3%typical
Long-stay residents with pressure ulcers6.7%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control5.0%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table50.0%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Long-stay hospitalizations per 1,000 resident days2.232.111.67worse
Long-stay outpatient ER visits per 1,000 resident days5.362.331.80worse

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.

11.6%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF11.6%CMS range 8.1–16.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this 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

0.20
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.02
Total nurse hours/ resident / day
0.21
RN hoursweekends
55.6%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 72.5 residents a day — about 84% occupied, or roughly 14 beds typically open. It usually has some room. 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.67 hrs/resident/day on weekends vs 3.16 on weekdays — 16% thinner on weekends. RN hours go from 0.19 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

10
deficiencies at the latest standard inspection (2026-03-19)
4
at the previous standard inspection (2025-01-09)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · F2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 71.The facility did not provide a policy regarding dietary. 1. Observation on 03/17/26 at 9:50 A.M., 03/18/26 at 10:23 A.M., and 03/19/26 at 6:16 P.M., of the kitchen showed: - One compartment and three compartment sinks with the hot side water temperature at 106 degrees Fahrenheit after one minute;- One large metal cookie sheet with dark brown carbon build-up in the corners and one small cookie sheet with carbon build-up in the corners; - The commercial gas range oven with excessive black grime build-up on all interior surfaces and on the floor beneath; - One dented 3-quart can of spinach, dated received on 03/03/26;- One dented 50-ounce can of cream of mushroom condensed soup, dated received on 03/03/26;- The commercial dishwasher interior and exterior with flaky white grime (dirt ingrained on the surface of something) build-up and…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 refund resident funds within 30 days of when a resident expired for three residents (Residents #80, #81 and #82) out of three sampled residents. The facility census was 71.Review of the facility's policy titled, Accounting and Records of Resident Funds, revised [DATE], showed:- The facility maintains accounting records of resident funds on deposit with the facility;- Individual accounting ledgers are maintained in accordance with generally accepted accounting principles;- Inquiries concerning a resident's personal funds account record are referred to the Administrator or to the business office. 1. Review of Resident #80's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #80 had $93.13 held in the resident trust fund account as of [DATE] (121 days late). 2. Review of Resident #81's closed medical record showed:- The resident expired on [DATE].…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure a homelike environment was provided for the residents residing on the Men's Locked Behavior Unit which affected 12 residents with the potential to affect all 15 residents on the unit. The facility also failed to provide a safe, clean, and comfortable homelike environment which could have the potential to affect all residents in the facility. The facility census was 71. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed:- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible;- Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences;- The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. 1. Observation on 03/17/26 at 12:05 P.M., of the Men's Locked Behavior Unit showed:-…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 failed to provide an appropriate diagnosis for the use of an antipsychotic (medication to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for two residents (Residents #9 and #16) and failed to attempt a gradual dose reduction (GDR) for an antipsychotic medication for one resident (Resident #16) out of five sampled residents. The facility census was 71. Review of the facility's policy Psychotropic Medication Use, revised 02/2025, showed:- An adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: a. an assessment of the resident's condition and therapeutic goals;b. a determination that non-pharmacological interventions are clinically contraindicated;- Psychotropic (any medication that affects brain activity associated with mental processes and behavior) medication may be considered appropriate when: a. a resident's…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 provide the amount a bed would be held for on the bed hold policy upon transfer to the hospital and failed to include the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsmen (advocate for the resident in nursing facilities), the mailing and email address for the agency for protection and advocacy for residents with intellectual disabilities, and the mailing, email address, and telephone number for the agency for protection and advocacy for residents with mental illness, within the transfer and discharge notices for four residents (Residents #1,#3, #24, and #41) out of four sampled residents. The facility census was 71.Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed:- All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop and implement a baseline care plan for one resident (Resident #43) out of one sampled resident that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 73.Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed:- A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;- The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, discussion with the resident/representative, and physician orders;- The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed;- Provision…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 placement of the urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was maintained for two residents (Residents #1and #5) out of two sampled residents. The facility census was 71. Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;- Be sure the catheter tubing and drainage bag are kept off the floor;- Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of neurogenic bladder (the bladder does not empty properly due to a neurological condition) and urinary tract infection. Review of the resident's Physician Order Sheet (POS), dated March 2026, showed:- An order to flush the…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 training was provided, competence was assessed, and a physician's order was received for laryngectomy tube ([NAME] tube - a flexible silicone tube inserted into the stoma (neck opening) to maintain the airway opening) care to be completed independently, and the type and size of the [NAME] tube supplies, and to have all of the needed [NAME] tube supplies easily accessible for one resident (Resident #5) out of one sampled resident with a [NAME] tube. The facility also failed to follow the physician's order for supplemental oxygen therapy and to change, date, and store the oxygen tubing (flexible tubing that delivers supplemental oxygen through the nostrils) and the nebulizer (a medical device that converts liquid medication into a mist to be inhaled directly into the lungs) tubing for one resident (Resident #43) out of two sampled residents. The facility census was 71.The facility did not provide a policy regarding oxygen tubing and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for three residents (Residents #9, #13, and #16) out of three sampled residents. The facility census was 71.Review of the facility's policy titled Dementia - Clinical Protocol, dated November 2018, showed:- The interdisciplinary team (IDT) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes;- For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life;- Direct care staff will support the resident in initiating and completing activities and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 follow appropriate infection control practices with hand hygiene and glove changes during wound care, and suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) care for one resident (Resident #1) and incontinent care for three residents (Residents #5, #38, and #75) out of three sampled residents. The facility failed to follow appropriate infection control practices when inserting a nasal cannula (a device used to deliver oxygen with two small tubes that fit into the nostrils) into the nares of one resident (Resident #38) after it lay on the floor. The facility census was 71. Review of the facility's policy, Handwashing/Hand Hygiene, dated October 2023, showed:- This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections;- All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection;- Hand hygiene is indicated immediately before touching a 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 70. Review of the facility's policy titled, Homelike Environment, revised on February 2021, showed; - Residents are provided with a safe, clean, comfortable and homelike environment. The facility did not provide a maintenance log. 1. Observations on 01/08/25 at 8:22 A.M., and 01/09/25 at 8:52 A.M., of the dining room and the C unit showed: - A deep crack in the laminate flooring across the middle of the dining room, approximately 15 foot (ft) in length and approximately 1 inch (in) deep causing a shift in the walking surface; - Approximately 20 ft of missing baseboard trim along the entire dining room wall near the kitchen; - Exposed sheetrock approximately 20 in x 20 in in the C unit hallway. During an interview on 01/09/25 at 10:27 A.M., the Maintenance Supervisor (MS) said the crack in the dining room floor had been there since he/she had…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for three residents (Residents #16, #24, and #58) out of five sampled residents. The facility census was 70. Review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised July 2022, showed: - After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; - Residents who use psychotropic (medications that affect the mind, emotions, and behavior) medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; - The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident; - The physician will review periodically whether current medications are still necessary in their current doses. For example, whether an…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 maintain a medication error rate of less than five percent (%). There were 28 opportunities with two errors made, resulting in an error rate of 7.14% for two residents (Residents #23 and #58) out of six sampled residents. The facility's census was 70. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The staff will have access to specific instructions from the manufacturer on all forms of insulin delivery systems; - The policy did not address insulin pen administration technique. Review of the Fiasp (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flextouch Pen (insulin in a pen-type device) instructions, revised, June 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle is pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, the insulin will 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 implement Enhance Barrier Precautions (EBP) during tube feeding (liquid food delivered into the stomach by a tube) and incontinent care for one resident (Residents #21) out of four sampled residents. The facility census was 70. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - EBP is used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms; - Gloves and gown are applied prior to performing high contact resident care activity; - Examples of high-contact resident activities requiring EBP include: dressing, bathing, transferring, hygiene care, changing linens, changing briefs and assistance with toileting, device care or use for central line, feeding tube, tracheostomy/ventilator etc.) and wound care. 1. Observation on 01/08/25 at 11:12 A.M., of Resident #21's tube feeding administration showed: - EBP signage posted outside of the resident's room; - Licensed Practical Nurse (LPN) C did not put on an isolation gown,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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 provide resident care for activities of daily living (ADL's) when the facility did not provide showers at least weekly for five residents (Resident #8, #18, #23, #26, and #31) and at least twice weekly for one resident (Resident #38) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to shower frequency. Review of the shower list showed: - Resident #8 scheduled for a shower once a week on Tuesdays; - Resident #18 scheduled for a shower once a week on Wednesdays; - Resident #23 scheduled for a shower once a week on Fridays; - Resident #26 scheduled for a shower once a week on Tuesdays; - Resident #31 scheduled for a shower once a week on Wednesdays; - Resident #38 scheduled for a shower twice a week on Tuesdays and Fridays. 1. Review of Resident #8's medical record showed: - An admission date of 04/12/23; - Diagnoses of hypertension (high blood pressure), malnutrition, anxiety (persistent…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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

    Based on observation, interview, and record review, the facility failed to provide care in a manner that enhanced the resident's dignity while eating for one resident (Resident #65) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Resident Rights and Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents will be treated with dignity and respect at all times; - Residents will be provided with a dignified dining experience. 1. Review of Resident #65's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility,dated 07/27/23, showed: - Cognition moderately impaired; - Requires limited assist of one staff for eating. Review of the resident's medical record showed: - admission date of 07/22/22; - Diagnoses of autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), schizophrenia…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintain a safe, clean, comfortable, and homelike environment. The deficient practice had the potential to affect all residents in the facility. The facility's census was 69. The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment. Observations of E hallway showed: - On 09/26/23 at 9:01 A.M., Room E3 with a 2 foot (ft.) x 4 inch (in.) puddle of liquid in the floor under the bedside table at the side of the bed; - On 09/26/23 at 12:17 P.M., Room E3 with a 2 ft. x 4 in. puddle of liquid in the floor under the bedside table at the side of the bed. The floor was sticky and the room had a strong urine odor. The bathroom floor with a 1/2 in. gap in tile in front of the toilet; - On 09/26/23 at 12:20 P.M., Room E5's bathroom with the cove base pulled away from wall behind the right side of the toilet and with an approximate 20 in. x 3 in. hole in the sheet rock behind the cove base with a black discoloration to the insulation; - On 09/26/23 at 12:24 P.M., Room E8's…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of a trapeze (a device designed to assist residents in changing positions) for two residents (Resident #7 and #21) out of two sampled residents and failed to complete a resident assessment and safety evaluation for the use of a trapeze for one resident (Resident #21) out of two sampled residents. The facility census was 69. The facility did not provide a policy regarding trapeze use. 1. Review of Resident #7's Physician's Order Sheet (POS), dated September 2023, showed: - admission date of 11/18/22; - Diagnoses of renal (kidney) failure, obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety (persistent worry and fear about everyday situations), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); -…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 follow physician's orders for two residents (Resident #8 and #21) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #8's Physicians Order Sheet (POS), dated August 2023, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and chronic respiratory failure whether with hypoxia (the absence of enough oxygen in tissues to sustain bodily functions) or hypercapnia (buildup of carbon dioxide in bloodstream); - An order for oxygen tubing (the tube delivering oxygen from the oxygen container to the person) to be changed, dated 04/12/23. The order did not address how often to change the oxygen tubing; - An order for oxygen five liters per minute (LPM), dated 04/12/23. Review of the resident's medical record showed the oxygen initialed by staff which indicated the resident received oxygen five LPM daily. Observations…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    Based on observation, interview, and record review, the facility failed to provide adequate supervision of two residents residing on the secured behavioral unit during smoking which affected one resident (Resident #51) out of two sampled residents and one resident (Resident #20) outside of the sample. The facility census was 69. Review of the facility's policy titled, Smoking, dated 5/2021, showed: - Smoking is allowed in designated areas only; - All residents will be monitored by facility staff when smoking; - No resident may smoke unattended unless specifically care planned to do so. 1. Review of Resident #20's medical record showed: - Date of admission of 04/21/21; - Diagnoses of major depressive disorder (MDD) (a persistent depressed mood, or loss of interest), unsteadiness of feet, muscle weakness, unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decision and solve problems), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), traumatic brain…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 maintain an effective pest control program to control the fly and gnat populations in the facility. This deficient practice had the potential to affect all residents. The facility census was 69. Review of the facility policy titled, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; - Windows are screened at all times; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. Observations of the B Hall showed: - On 09/28/23 at 10:51 A.M., two gnats flew around the toilet in room B7. The window was opened 4 inches and the screen separated from the window frame 1 inch (in.) near the center; - On 09/28/23 at 11:03 A.M., six gnats flew around the toilet in room B7; - On 09/28/23 at 11:57 A.M., twelve gnats flew…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PARADIGM SENIOR MANAGEMENT — 8 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 →

RatingThis homeChain avg
Overall 3 of 53.6-0.6 vs chain
Health inspection 4 of 54.6-0.6 vs chain
Staffing 1 of 51.1-0.1 vs chain
Quality measures 2 of 52.3-0.3 vs chain
The other 7 homes this chain runs (chain average 3.6★, 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 / managerTypeRoleSince
JONES, ANGELAIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2021
SELLS, BENJAMINIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2021
MRV BANKSOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
FORVIS MAZARS LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
PARADIGM REHAB SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
PARADIGM SENIOR MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
CALDWELL, FREDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2022
HUTCHINSON, DALENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2022
JONES, SONDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021
MONTGOMERY, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2022
SHIELDS, JAMIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021

CMS files one row per role, so the 22 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

$4.7M
Net patient revenuemost recent cost report
+2.7%
Operating marginrevenue minus expenses
$1.1M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 92%Medicare 4%Other / private 4%

About 92% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$180per resident / day
operating cost
$5,461per month
≈ monthly operating cost
$185per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

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 265368. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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.

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