Campbell Healthcare & Senior Living
17108 Us Highway 62, Campbell, MO 63933 · For profit - Corporation · 90 certified beds · (573) 246-2155 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (27) — 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)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 3 to 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.
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 | 19.3% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 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 | 2.5% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.5% | 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 | 0.0% | 4.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 9.4% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.0% | 25.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 70.8% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.0% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 10.0% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 40.9% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.0% | 13.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 4.06 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.88 | 2.33 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
31.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 31.3%CMS range 20.3–46.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.3–14.6 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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. | — | ||
| 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 | not 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 worsened | not 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 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 | 1.53 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 90 beds and averages 72.9 residents a day — about 81% occupied, or roughly 17 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 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.48 hrs/resident/day on weekends vs 3.08 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.43 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Fcited before2025-08-22 · 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, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions increasing the risk of cross-contamination. This deficient practice had the potential to affect all residents. The facility census was 63. Review of the facility's policy titled, Ice Machine Air Gap (prevents backflow of contaminated water into a potable (drinkable) water system) Compliance, undated, showed:- It is the policy of this facility to ensure that all ice machines used for resident dietary services, hydration, and medical needs are equipped and maintained with a properly installed and maintained air to prevent contamination of potable water supplies;- The purpose is to prevent backflow and contamination of water and ice;- To protect residents, staff, and visitors from foodborne illness or cross-contamination;- All ice machines must be installed with an air gap between the water supply line and the drain line;- The air gap must be at least two times the diameter of the drain line, be visible and accessible for inspection, 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.
- Potential for harm · D2025-08-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 electronically transmit Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) in a timely manner and in accordance with guidelines for three residents (Residents #27, #36 and #51) out of three sampled residents. The facility census was 63.Review of the facility's policy titled, MDS Submission, undated, showed:- It is the policy of this facility to complete and submit all MDS assessments timely, accurately, and in compliance with Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual standards and Missouri regulatory requirements. Submissions must be completed in the Internet Quality Improvement and Evaluation System (IQIES) and meet Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) deadlines to avoid penalties;- Complete all required MDS assessments;- Submit electronically via iQIES per CMS requirements;- Confirm successful transmission by…
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 · D2025-08-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop and implement a care plan with specific interventions tailored to meet individual needs for three residents (Residents #5, #51, and #71) out of 16 sampled residents. The facility census was 63. Review of the facility's policy titled, Comprehensive Care Plans, undated, showed: - It is the policy of this facility to ensure that every resident is admitted to the skilled nursing facility has a comprehensive, person-centered care, plan, developed, implemented, and reviewed according to federal and state regulations; - To promote quality of life, safety, and optimal outcomes for each resident; - To involve the resident and/or representative and care decisions; - A comprehensive assessment must be completed within 14 days of admission; - The baseline care plan will be completed within 48 hours of admission; - The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment; - The plan 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 · D2025-08-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 update and revise care plans with specific interventions tailored to meet individual needs for two residents (Residents #12 and #58) out of 16 sampled residents. The facility census was 63.Review of the facility's policy titled, Revising Care Plans, undated, showed:- It is the policy of this facility to ensure that all comprehensive care plans are reviewed and revised promptly to reflect changes in the resident's condition, treatment, or goals of care;- Care plan revisions are essential to ensure individualized, person-centered, and safe care and to promote accurate, updated interventions that reflect the resident's needs and preferences;- Care plans must be reviewed and revised quarterly, upon a significant change, new physician's orders that impact resident care, after hospitalizations or acute medical events, and upon resident/family request or concerns;- Nurses and other direct care staff must promptly notify the Interdisciplinary…
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 · D2025-08-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of four medication carts and one out of one medication storage room. This practice had the potential to affect all residents. The facility census was 63.Review of the facility's policy titled, Narcotic Medication Reconciliation Policy and Procedure, undated, showed:- The purpose of this policy is to ensure accurate reconciliation of all narcotic medications when received, transferred, or discontinued in the facility, prevention diversion, loss, or administration errors;- All narcotic medications must be reconciled at key transition points: admission to the facility, receipt from the pharmacy, change of shift counts, discontinuation or destruction of narcotics;- Narcotic reconciliation requires two licensed nurses whenever possible;- All discrepancies must be immediately reported to the Director of Nursing (DON) and Administrator;- Documentation in 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.
- Potential for harm · Dcited before2025-08-22 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 implement enhanced barrier precautions (EBP) when staff performed incontinent care for one resident (Resident #6) and indwelling catheter (a flexible tube inserted into the bladder to drain urine) care for one resident (Resident #13) out of three sampled residents. The facility census was 63. Review of the facility's policy titled, Enhanced Barrier Precautions, last reviewed 07/15/25, showed:- Will follow Centers for Disease Control and Prevention (CDC) guidelines for EBP to reduce the transmission of multidrug-resistant organism (MDRO's) in nursing home settings. EBP will be used for residents with wounds, indwelling medical devices, or other risk factors- regardless of know colonization status;- This policy applies to all direct care staff, including nurses, certified nurse aides (CNA's), therapy staff, and other personnel involved in resident care;- EBP: Use of gloves and gowns during high-contact resident care activities, even when…
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 · D2025-08-22 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 conduct inspections of all bed frames, mattresses, and side rails as a part of a regular maintenance program for three residents (Residents #5, #40, and #52) out of three sampled residents and one resident (Resident #43) outside the sample. The facility census was 63. Review of the facility's policy titled, Side Rail Assessment, undated, showed: - It is the policy of this facility that side rails (bed rails) will not be used as restraints and will only be implemented when medically, necessary, functionally, beneficial, on individualized assessment; - Side rails use must comply with regulations, guidance, and resident rights require requirements; - Upon admission, nursing staff must complete a side rail risk/benefit assessment; - Assessment must address medical need (mobility, repositioning aid, transfers); - Resident preference in history; - Cognitive status and entrapment risk; - A physician's order is required for side rail use; -…
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 before2024-09-12 · 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, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 72. Review of the facility's policy titled, Sanitation, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchen areas and dining areas are kept clean; - All utensils, counters, shelves and equipment are kept clean, maintained in good repair and free of breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in the refrigerator or freezer are covered, labeled and dated; - Functioning of the refrigerators and food temperatures are monitored daily and at designated intervals throughout…
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 · D2024-09-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 ensure staff treated residents with dignity and in a respectful manner by leaving two residents (Residents #9 and #11) out of 18 sampled residents exposed during care. The facility census was 72. The facility did not provide a policy regarding maintaining a resident's dignity. 1. Review of Resident #9's medical record showed: - admission date of 05/20/24; - Diagnoses of cerebral infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing), apraxia following unspecified cerebrovascular disease (neurological disorder that makes it difficult to perform certain movements), contracture, right hand (a permanent tightening of muscles, tendons, causing the joints to shorten and become stiff); Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 08/14/24 showed: - Cognition severely impaired; - Always incontinent of bowel; - Dependent (helper does all the effort) for toileting hygiene;. Observation of 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 · Dcited before2024-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 72. 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; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include a clean, sanitary and orderly environment. 1. Observations made on 09/09/24 at 9:38 A.M. and 09/11/24 at 11:02 A.M., of the 500 hall unit, showed: - A three foot (ft.) piece of base trim peeled off the bottom wall of the closet located in room [ROOM NUMBER]; - A piece of wood trim hung off the bottom of the closet onto the floor located in room [ROOM NUMBER]. -…
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 17 citations
- Potential for harm · D2024-09-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the resident's responsible party and to the representative of the Office of Long-Term Care (LTC) Ombudsman (a program that advocates for residents, provides information and help resolve problems) for three residents (Residents #9 and #21) out of four sampled residents. The facility census was 72. Review of the facility's policy titled, Transfer or Discharge Policy, revised March 2021, showed: - Residents and/or representatives are notified in writing, and in a language and format they understand prior to transfer or discharge; - The resident and representative are notified in writing of the specific reason for transfer, the effective date, the location, and the bed-hold policy; - The reasons for the transfer or discharge are documented in the resident ' s medical record; - The policy did not address sending a monthly transfer log to the Office of the State LTC…
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 · D2024-09-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility) assessment within 14 days for one resident (Resident #66) out of three sampled closed resident records. The facility's census was 72. Record review of the facility's policy titled, Comprehensive Assessments, revised October 2023 , showed: - Comprehensive MDS assessments are conducted to assist in developing person-centered plans; - Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (ITD, a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) has determined that a resident meets the significant change guidelines for either major improvement or decline; - The policy did not address a timeframe to submit a significant change. 1. Record review of Resident #66's medical record showed: - An admission date of 02/09/24; - admitted to hospice (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 · D2024-09-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #9) out of 18 sampled residents and one resident (Resident #15) outside the sample. The facility's census was 72. The facility did not provide a MDS policy. 1. Review of Resident #9's medical record showed: - admission date of 05/20/24; - Diagnoses of cerebral infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing), apraxia following unspecified cerebrovascular disease (neurological disorder that makes it difficult to perform certain movements), - Resident had a fall and sent to hospital on [DATE]; Review of the resident's admission MDS, dated [DATE], showed no prior falls. Review of the resident's quarterly MDS, dated [DATE], showed: - No falls; - The facility did not code the resident's MDS accurately. 2. Review of Resident #15's medical record showed: - admission date of 06/12/23; - Diagnoses…
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 · D2024-09-12 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide documentation of a Level I Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for two residents (Residents #21 and #43) out of 18 sampled residents. The facility's census was 72. The facility did not provide a PASARR policy. 1. Review of Resident #21's medical record showed: - An admission date of 07/30/23; - Diagnoses of schizophrenia (a disorder that affects one's ability to think, feel and behave clearly) violent behavior and generalized anxiety disorder (an excessive, ongoing anxiety and worry that are difficult to control); - No level I PASARR. 2. Review of Resident #43's medical record showed: - An admission date of 07/30/21; - Diagnoses of psychotic disorder (a mental disorder characterized by a disconnection from reality), traumatic brain injury (TBI) (an injury to the brain) and dementia (thinking and social symptoms that interfere with…
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 · D2024-09-12 · tag F0655 — isolatedCreate 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the baseline care plan (initial plan for delivering of care and services) included specific interventions and the resident and/or guardian received a written summary of the baseline care plan for one resident (Resident #120) out of two sampled residents. The facility was census was 72. Review of the facility's policy titled, Baseline Care Plan Policy, revised 03/2022, showed: - The baseline care plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b.…
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 · D2024-09-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's order for fall mats (a soft landing surface to help prevent injuries) for one resident (Resident #6) out of two sampled residents. The facility census was 72. Review of the facility's policy titled, Attending Physician Responsibilities, revised August 2014, showed: - The attending physician's shall be the primary practitioners responsibility for providing medical services and coordinating the healthcare of each resident in the facility; - The physician will provide orders to ensure that individuals have appropriate comfort and supportive measures as needed; - The policy did not address facility following physician orders. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - Diagnoses of abnormal involuntary (cannot control) movements, epilepsy (a disease that causes recurrent seizures), and muscle spasm (involuntary tightening of a muscle or group of muscles). Review of the resident's Physician Order Sheet (POS),…
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 · D2024-09-12 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 identify, assess and provide supportive interventions for one resident (Resident #52) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 72. Review of the facility's policy titled, Trauma Informed Care, revised March 2019, showed: - To guide staff in appropriate and compassionate care specifics to individuals who have experienced trauma; - All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting; - Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization; - As part of the comprehensive assessment, identify…
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 · D2024-09-12 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 sufficient nursing staff to answer call lights in a timely manner to meet each resident's rights, physical, mental and psychosocial (how someone feels and copes with changes in their social environment) well-being. The deficient practice had the potential to affect all residents in the facility. The facility census was 72. Review of the facility's policy titled, Answering the Call Light, undated, showed: - The purpose of this procedure is to respond to the resident's requests and needs; - Explain the call light to the new resident; - Demonstrate the use of the call light; - Ask the resident to return the demonstration so that you will be sure that the resident can operate the system; - Be sure the call light is plugged in and functioning at all times; - When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident; - Some residents may not be able to use their call light, provide…
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 before2024-09-12 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 maintain proper infection control practices during incontinent care for one resident (Resident #9) out of four sampled residents and during wound care for one resident (Resident #24) out of two sampled residents. The facility failed to follow enhanced barrier precautions (EBP) for four residents (Residents #7, #9, #11 and #31) out of six sampled residents during care. The facility also failed to implement a risk management process specific to Legionella disease (a serious type of pneumonia caused by legionella bacteria) which had the potential to affect all residents, staff and the public. The kitchen staff failed to perform hand hygiene between the residents during a meal pass. The facility census was 72. Review of the facility's policy titled, Wound Care, revised, October 2019, showed: - Put on gloves, loosen tape and remove dressing; - Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly; - Put on gloves; - Use a no-touch technique to apply creams and ointments.…
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 · D2024-09-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to document pertinent education provided to the residents or the resident's representative regarding benefits, side effects or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for five residents (Residents #2, #6, #21, #24, and #31) out of five sampled residents. The facility's census was 72. Review of the facility's policy, titled, Influenza Vaccine, revised March 2022, showed: - Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record. - A resident's refusal of the vaccine shall be documented on the informed consent for the influenza vaccine and placed in the resident's medical record. Review of the facility's policy, titled, Pneumococcal Vaccine, revised March 2022, showed: - Before receiving a pneumococcal vaccine, the resident or legal…
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 · D2024-09-12 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview an record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year for two out of two Certified Nurse Aides (CNA) out of two sampled CNAs. The facility census was 72. Review of the policy titled, In-Service Training, All Staff, revised August 2022 showed: - All staff must participate in initial orientation and annual in-service training. - The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. - Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. topic of the training; c. the method used for training' d. a summary of the competency assessment; and e. the hours of training completed. 1. Review of CNA N's April 2023 through April 2024 in-service records showed: - Hire date of 04/07/23; - No documentation of annual in-service trainings provided;…
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 · F2023-04-21 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
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 answer call lights in a timely manner nor did they ensure staff had functioning call devices in their possession to answer resident calls via the wireless nurse call system per the facility's call light exception, approved by the Department of Health and Senior Services (DHSS). This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's exception letter, approved by DHSS, dated 11/27/19 showed, the facility is required to comply with the stipulations that follow: 1. The operator will ensure the wireless nurse call system is fully operational twenty-four (24) hours per day, seven (7) days a week. 2. The operator shall maintain, at a minimum, all the features of the CISCOR [NAME] 9000 wireless call system provided to the SLCR on November 13, 2019, and notify the SLCR of system changes. 3. The operator will ensure that all direct care staff carry and utilize 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.
- Potential for harm · Ecited before2023-04-21 · 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, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Record review of the facility's Maintenance Service policy, undated, showed: - Maintenance service shall be provided to all areas of the building, grounds and equipment; - The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner; - The Maintenance Director is responsible for inspections of the building and work order requests; - Records shall be maintained in the Maintenance Director's office. 1. Observations on 4/18/23 at 9:32 A.M., 4/19/23 at 9:10 A.M., and 4/20/23 at 9:03 A.M., of 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.
- Potential for harm · D2023-04-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 a code status was consistently documented throughout the medical record for two residents (Residents #29 and Resident #33 ) out of 14 sampled residents. The facility census was 56. Record review of the facility's Advance Directives policy, undated, showed: - Advance directives will be respected in accordance with state law and facility policy; - The plan of care for each reach resident will be consistent with his/her documented treatment preferences and/or advance directive; - The interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) will review annually with the resident his/her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident Minimal Data Set (MDS) (a federally mandated assessment instrument completed…
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 · D2023-04-21 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #63) out of one sampled discharged resident. The facility census was 56. 1. Record review of Resident #63's closed medical record showed: - admission date of 7/19/22; - Diagnoses of chronic pain syndrome (a type of pain that persists for three months or longer), depression (a serious medical illness that negatively affects how a person feels, thinks, and acts), anxiety (persistent worry and fear about everyday situations), hypertension (high blood pressure), and myocardial infarction (a heart attack); - The resident to be his/her own responsible party; - No documentation which addressed the resident's preference and potential for future discharge; - No…
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 · D2023-04-21 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #63) out of one sampled discharged resident. The facility census was 56. Record review of the facility's Discharge of Resident/Recapitulation of Stay policy, undated, showed: - Social services will initiate the discharge packet upon notification of plans to discharge by the resident or the responsible party; - A discharge meeting will be arranged to include the resident, family or power of attorney (POA) (legal authorization for a designated person to make decisions about another person's property, finances or medical care), and a representative from social services, activities, dietary, nursing and therapy departments; - The interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) members will complete the discharge plan of care; - At the time of discharge, a Licensed Nurse (LN) will review the discharge plan of care and medications with 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.
- Potential for harm · Dcited before2023-04-21 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 infection prevention and control interventions designed to prevent the development and transmission of communicable diseases and infections and failed to provide a safe and sanitary environment by not wearing source control (facemasks) based on the community transmission (CT) level (the amount of Coronavirus Disease 2019 (COVID-19) (a highly contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (a member of a large family of viruses called coronaviruses) spread within each county), having the potential to affect all residents, and failed to disinfect the glucometer (a device used to measure blood sugar) per the manufacturer's instructions and failed to sanitize hands for one sampled resident (Resident #27) and six residents (Resident #47, #8, #41, #17, #7 and #36) outside the sample. The facility also failed to perform proper glove change from dirty to clean care during incontinent care for two residents (Resident #6 and #30) outside the sample. 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.
“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 POINTE MANAGEMENT — 12 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 | 1.3 | +1.7 vs chain |
| Health inspection | 4 of 5 | 2.2 | +1.8 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 1.2 | +0.8 vs chain |
The other 11 homes this chain runs (chain average 1.3★, 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 |
|---|---|---|---|---|
| LINCOLN HCG LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 04/01/2023 |
| S & C HOLDINGS ILLINOIS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 30% | since 04/01/2023 |
| STONEWALL HCG LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 04/01/2023 |
| CHANKIN, KEVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 04/01/2023 |
| MERMELSTEIN, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 04/01/2023 |
| COLE, JOHN | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2023 |
| POINTE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| LEVOVITZ, YERUCHOM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| WEBSTER, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
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.
This home reported $480K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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
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 265677. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-22, 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 →
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