St Luke's Nursing And Rehabilitation
1220 East Fairview, Carthage, MO 64836 · Non profit - Corporation · 95 certified beds · (417) 358-9084 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
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (1/5)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 | 22.3% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 5.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.3% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.7% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 18.5% | 6.5% | check this* — see note marked star 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 | 2.9% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.2% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 25.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.7% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.1% | 63.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 32.2% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 29.2% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.30 | 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.
49.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 92 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 40.4–60.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.5–15.2 | 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 | 55.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 57.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.6–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 95 beds and averages 84.6 residents a day — about 89% occupied, or roughly 10 beds typically open. It runs fairly full. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.63 on weekdays — 12% thinner on weekends. RN hours go from 0.44 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below 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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · F2025-05-09 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to ensure meals were served at a palatable temperature when staff failed to verify temperature of food to ensure proper holding temperature prior to starting meal service resulting in cold food not held at 41 degrees Fahrenheit (F) or lower. The facility had a census of 64. Review of the United States Department of Agriculture (USDA) website, food safety basics section titled, Danger Zone (40 degrees F to 140 degrees F), revised 06/28/17, showed the following information: -Cold food is to be kept at 40 degrees Fahrenheit or lower and placed in containers on ice; -Bacteria grows most rapidly in temperature ranges between 40 degrees F and 140 degrees F. Review of a facility policy titled Food Handling, dated 01/20/15, showed the following information: -Hot food is to be held at a minimum of 135 degrees F or higher; -Cold food is to be held at a minimum of 41 degrees F or lower; -Dietary staff were responsible for maintaining food temperature and documenting on temperature logs. 1. Review of the facility menu,…
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 · F2025-05-09 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews the facility failed to maintain quarterly Quality Assessment Committee (QAA) meetings with the required members when the Medical Director did not attend the QAA meetings. The facility census was 64. Review of the facility's Quality Assurance Committee policy, dated 06/11/07, showed the following: -Purpose to set forth guidelines for the formation and maintenance of a Quality Assurance Committee. -The Quality Assurance Committee will audit criteria in each department that are set by the committee which review work processes and procedures. These audits will be performed monthly by the department head; -The Quality Assurance Committee shall consist of the following membership: the administrator, the director of nursing (DON), the social service director (SSD), the activities director (AD), the dietary supervisor (DS), the laundry/housekeeping supervisor (LKS), the maintenance supervisor (MS) and the medical director (MD); -The Quality Assurance Committee will meet routinely the second Tuesday of each month; -This meeting is attended by all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-09 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed ensure each resident's right to receive mail correspondence timely was honored when staff failed to provide mail delivered on Saturdays to residents timely. The facility census was 64. Review of the facility did not provide a policy addressing delivery of mail to residents on the weekend. 1. During the resident council meeting on 05/06/25, at 2:00 P.M., the residents in attendance said mail was only delivered to residents Monday through Friday and was not delivered to the residents on the weekends. The residents said they would like to receive any mail that comes in on Saturdays if possible. The residents said mail was only delivered on Saturdays if the Activity Director was working as the weekend department head. No other staff deliver mail to residents on Saturdays. During an interview on 05/08/25, at 11:30 A.M., Activity Assistant I said he/she works days Monday through Thursday. He/she does not pass the mail to the residents. The Activity Director passes mail during the week. During an interview on 05/08/25, at 11:40…
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 · E2025-05-09 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 an ongoing program of activities designed to meet all residents' interests when staff failed to ensure an variety of activities were provided by facility staff on the weekends. A sample of 19 residents and the group interview of seven residents were selected in a facility with a census of 64. Review of the facility's current policy related to activities showed it did not address activities provided by staff for the residents on the weekend. 1. During the group interview on 05/06/25, starting at 2:07 P.M., residents said the following: -The only activity during weekends was bingo on Saturdays; -This activity was run by another resident (Resident #7) in the facility; -The Activity Director and activity assistants do not work weekends; -Resident #7 said if he/she overslept or was sick then there was no Bingo or activity for that Saturday; -The residents said the only thing going on Sundays was church; -The residents said they get bored on weekends and would like more scheduled activities for Saturdays…
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 · D2025-05-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 ensure all allegations of possible abuse were reported to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report a resident to resident allegation of physical abuse between two residents (Resident #26 and #32). The facility had a census of 64. Review of the facility's policy titled Abuse, Neglect, Misappropriation, and Injury of Unknown Origin Policy, dated June 2023, showed the following: -Facility policy is to prohibit all forms of abuse, neglect, and exploitation of any resident; -Any suspicion or allegation of abuse, neglect, or misappropriation of patient property or funds will be reported immediately and investigated thoroughly; -Staff will notify the Administrator and/or Director of Nursing (DON) immediately, within 15 minutes of the alleged incident; -If the nature of the incident is unclear or is suspicious of abuse, neglect, misappropriation, or injury of unknown origin, DHSS will be notified…
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 · D2025-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to provide an environment free from accident hazards when staff failed to use a gait belt (a safety device used to provide support when transferring a person from one position to another) when transferring and assisting one resident (Resident #40), with a history of falls, to toilet. The facility census was 64. The Administrator was notified on the morning of 11/15/24 of the Past Non-Compliance which occurred on 11/15/24. Staff completed an investigation into the cause of the fall and complete counseling with the involved staff member on 11/18/24. Inservices with all nursing staff were also conducted on 11/18/24. The noncompliance was corrected on 12/17/24. Review of the facility's policy titled Incidents and Accident, dated 03/06/07, showed the following: -Purpose was to prevent falls and to provide the resident with a sense of security; -Equipment and supplies necessary when assisting residents to the bathroom included a gait belt; -Assist the resident to a standing position, move slowly, and allow 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 · E2023-07-17 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (if the resident wished to receive assistance if his/her heart stopped beating or he/she stopped breathing) was easily accessible to staff in the event of an emergency and failed to ensure the status matched throughout the medical record for three residents (Residents #23, #12 and #125), out of seven sampled residents. The facility census was 74. Review showed the facility did not provide a written policy regarding the documentation of residents' preferred code status. 1. Review of Resident #23's face sheet (gives basic profile information) showed the following information: -admission date of [DATE]; -Diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system)), major depressive disorder, mood disorder due to known physiological condition with depressive features, and pain. Review of the resident's face sheet showed the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-17 · tag F0880 — failed to prevent and control infections — patternProvide 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 use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants, when staff failed to complete appropriate hand hygiene during wound care for three residents (Resident #41, #22, and #17) and during incontinent care for one resident (Resident #35). The facility census was 74. Review of the facility provided policy, Hand Hygiene, dated 11/02/19, showed the following: -Alcohol based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers and are the preferred method of cleaning your hands in most clinical settings; -The use of gloves does not replace hand hygiene; -Staff should perform hand hygiene with alcohol based hand sanitizer during routine care, immediately before touching a resident, before performing an aseptic task, before moving from work on a soiled body site to a clean body site on the same resident, after…
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 · D2023-07-17 · 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
Based on interview and record review, the facility failed to give written transfer notice to the resident and/or resident's representative for two residents (Residents #45 and #69) who were transferred out to the hospital. A sample of two residents were reviewed in a facility with a census of 74. Review of a facility policy entitled Notice of Hospital Transfer/Room Hold Policy, dated 04/08/19, showed when staff send a resident to the hospital, the discharging nurse will give the resident a copy of the Notice of Hospital Transfer and Bed Hold Authorization which should contain/involve the following: -The resident's name is to be written on the first line; -The current room rates are to be entered on the appropriate lines; -The reason for transfer is to be written on the lines at the bottom of the form in language the resident can understand; -Two copies are to be made of the form. One is to be placed in the resident's chart under the miscellaneous tab, and the other is to be placed in the Director of Nursing (DON) bin at the nurses' station; -The original is to be sent to 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 · D2023-07-17 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 all residents or responsible parties received a written notice of the bed-hold policy upon transfer, when staff failed to provide two residents (Residents #45 and #69) of two sampled residents written notices of the facility's bed-hold policy when transferred to the hospital. The facility census was 74. Review of a facility policy entitled Notice of Hospital Transfer/Room Hold Policy, dated 04/08/19, showed the following: -All residents/responsible parties/representatives will be made aware of the facility room hold policy at the time of admission; -When a resident is sent to the hospital, the discharging nurse will give the resident a copy of the Notice of Hospital Transfer and Bed Hold Authorization that will include the resident's name is to be written on the first line and current room rates; -A call will be made to the resident's responsible party/representative within 24 hours of the discharge to the hospital by the charge nurse on weekends and by Transitional Care or Nursing Management during the week…
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 9 citations
- Potential for harm · D2023-07-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure Minimum Data Sets (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) were accurate when staff failed to address one resident's (Resident #11) dialysis on the resident's MDS. The facility census was 74. Review of the facility policy titled MDS (Minimum Data Set - a federally mandated comprehensive assessment completed by facility), dated 4/9/19, showed the following information: -The purpose is to ensure MDSs are completed on all current residents in the proper time-frame and to develop a plan of care that reflects the resident's choices and goals for the care; -The MDS Coordinator will interview the charge nurses and family, the resident and/or the resident's representative will together develop a comprehensive person-centered care plan for each resident which will describe the services that re to be furnished to attain or maintain the resident's highest possible physical, mental and psychosocial well-being while allowing the resident to drive their care on a daily basis;…
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 · D2023-07-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, record review, and interview, the facility failed to ensure a medication error rate of less than 5%, when staff made two errors out of 25 opportunities resulting in an 8% error rate. Staff failed to follow a medication order and manufacturer guidelines to not crush a medication for one resident (Resident # 37), failed to prime an insulin pen and failed to ensure receipt of a meal or snack within 30 minutes of insulin administration for one resident (Resident #16). The facility had a census of 74. Review of the facility provided policy, Medication Pass, dated 04/10/19, showed the following: -All medications are to be passed within one hour before and one hour after the medication is due; -The five rights are to be observed during medication pass: right resident, right medication, right time, right dose, and right route; -All long acting or time release medications are not to be crushed. If a resident is unable to take a medication whole, notify the charge nurse so that he/she may notify the physician; -Check the medication label against the Medication…
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 · D2023-07-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for one resident (Resident #16) when administering insulin. The facility census was 74. Review of the facility provided policy, Medication Pass,dated 04/10/19, showed the following: -All medications are to be passed within one hour before and one hour after the medication is due; -The five (5) rights are to be observed during medication pass: right resident, right medication, right time, right dose, and right route. Review of facility provided policy, Insulin Pen Administration, dated 02/25/19, showed the following: -Administer insulin as ordered by physician; -The insulin pen is to be primed prior to each use to prevent the collection of air in the insulin reservoir and to prime the needle with the insulin before the dose is administered. Review of the Humalog (insulin lispro injection - fast-acting insulin used to control high blood sugar) manufacturer's insert, dated November 2019, showed the following:…
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 · D2023-07-17 · 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
Based on observation, interview, and record review, the facility failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for two residents (Residents #41 and #46) from a sample of two residents. The facility census was 74. Review of the facility provided policy, Side Rails and Entrapment Prevention, dated 02/06/20, showed the following information: -Purpose to provide resident with a safe and comfortable bed/sleeping environment through accurate ongoing assessment and a program that aids in preventing entrapment issues with side rails; -Every resident deserves a safe and comfortable bed and sleeping environment; -All beds and mattresses in the facility will be numbered with a number on the back of the headboard and the bottom of the mattress; -Maintenance will maintain a log of the mattress number associated with each bed number; -All beds in the facility will be checked monthly for safety related to all bolts intact, electrical cords without damage, and bed functions as intended as part of a preventative maintenance…
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 · E2020-02-11 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Family Care Safety Registry (FSCR - a state registry that provides mutliple checks on staff including a Crimianl Background Check) or a Criminal Background Check (CBC) prior to hire to ensure one staff (Licensed Practical Nurse (LPN) F), of six sampled staff members, did not have a disqualifying criminal background that would prevent the staff member from working in a certified long-term care facility per the facility's policy. The facility census was 69. Record review of the facility's policy and procedure, titled, Policy: Criminal Background Checks, dates 6/11/07 and revised 12/17/19, showed the following information: -Purpose toassure that all employees are appropriate for working with the elderly populations and staff and to aid in providing a safe environment for the elderly residents and facility staff; -All applicants for employment will complete a consent for a criminal background check to be done at the time they complete 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 · E2020-02-11 · tag F0923 — patternHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when eight residents' bathrooms did not have functioning exhaust vents. The facility had census was 69. 1. Observation on 2/07/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident rooms did not have function correctly when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. During an interview on 2/07/2020, at approximately 1:00 P.M., the Maintenance Supervisor (MS) said he did not know the residents' bathroom exhaust systems did not work
- Potential for harm · D2020-02-11 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 treatment/services in a timely manner to one resident (Resident #18) experiencing unrelieved pain. A sample of 19 residents was selected for review in a facility with a census of 69. Record review of the facility policy titled, Pain Management, dated 3/11/13, showed the following: -Purpose to provide guidelines for assessment of residents in relation to pain and assure the residents have pain medication ordered; -Residents unable to verbalize pain will be assessed using the pain assessment in advanced dementia (PAINAD) scale (a five item observation tool with total scores ranging from 0 to 10 based on a scale, 0 = no pain, 10 = severe pain); -Occasional labored breathing, short periods of hyperventilation = 1 point; -Noisy labored breathing, long periods of hyperventilation = 2 points; -Occasional moan or groan, low level speech with a negative or disapproving quality = 1 point -Repeated troubling calling out, loud moaning or…
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 · D2020-02-11 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 document identification and use of possible alternatives prior to use of side rails and failed to complete side rail assessments to ensure the side rails are appropriate for use for two residents (Resident #49 and Resident #55). The facility failed to identify, develop, and implement interventions for the use of side rails for one resident (Resident #55). A sample of 19 residents was selected for review in a facility with a census of 69. Record review of the facility's policy, titled, Side rails/Bed rails and Entrapment Prevention, dated 10/31/17, showed the following information: -Purpose to provide residents with a safe and comfortable sleeping/bed environment through accurate ongoing assessment and a program that aids in preventing entrapment issues with the side rails; -The resident's right to participate in care planning and make choices will be balanced with the facility's responsibility to provide care based on an individual…
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 · D2020-02-11 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 notify the physician and administrative staff and immediately intervene when one resident (Resident # 120) made a statement to nursing staff regarding feelings of being suicidal. This practice affected one resident out of a sample of 19. The facility census was 69. 1. Record review of Resident 120's face sheet showed the following information: -Original admission date on 9/16/19 and readmission from the hospital on [DATE]; -Diagnoses which included unspecified dementia with behavioral disturbance, disorientation, and other recurrent depressive disorders. Record review of the resident's physician progress note of the hospital summary, dated 12/12/19, showed the physician documented the resident suffers from a diagnosis of major neurocognitive disorder, possible Alzheimer's type, with behavioral disturbance with medical issues which will grow worse if the resident does not choose to adhere to the treatment program. Given the resident's diagnosis there…
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.
- 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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SHAFFER, DEANNA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2022 |
| SMART, HAROLD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2007 |
| EDDS, CHUCK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2022 |
| MARTINDALE, RICH | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| MCGUIRE, LARRY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2018 |
| MCKEE, ROGER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2022 |
| PIERJOK, JOE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2018 |
| ROUSE, NORMAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2021 |
| STUART, EMILY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2021 |
| SWINGLE, SANDY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2022 |
| THOMPSON, JAY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2022 |
| WAMPLER, MARGARET | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2021 |
| BROWNELL, CARI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/04/2022 |
| RENSHAW, MELINDA | Individual | ADP OF THE SNF | since 10/01/2024 |
CMS files one row per role, so the 38 rows in the source record cover these 14 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.
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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 265661. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-09, 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.