No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Morningside Center

1700 Morningside Drive, Chillicothe, MO 64601 · Government - County · 60 certified beds · (660) 646-0170 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseResident-funds citation (F0565)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • 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.

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

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
861 Fairway Dr · (660) 999-9987 · Call to confirm hours
Pharmacy
Hy-Vee0.6 mi
1210 Washington St · (660) 646-3638 · Call to confirm hours
Grocery
1210 Washington St · (660) 646-3638 · Call to confirm hours
Park
1503 Walnut St · (660) 646-4424 · Typically dawn to dusk
Place of worship

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 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.0%18.1%15.4%worse
Long-stay residents who lose too much weight4.5%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.4%1.1%0.9%better
Long-stay residents with a urinary tract infection12.6%2.3%2.0%worse
Long-stay residents with depressive symptoms2.7%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.0%4.1%3.3%worse
Long-stay residents whose ability to walk worsened16.4%17.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication23.2%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.1%90.9%95.3%typical
Long-stay residents with pressure ulcers3.4%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control24.0%17.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table34.9%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.7%63.5%79.4%better
Short-stay residents rehospitalized after admission30.0%26.0%22.6%worse
Short-stay residents with an outpatient ER visit29.1%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.702.111.67worse
Long-stay outpatient ER visits per 1,000 resident days5.532.331.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.1% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.1%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
65.1%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 65.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.1%CMS range 29.8–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.8–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.1%56.6%Oct 2024–Sep 2025CMS 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 discharge41.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.5%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.3%CMS range 4.8–15.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.98
RN hours/ resident / day
0.15
LPN hours/ resident / day
2.57
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.72
RN hoursweekends
50.7%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 52.8 residents a day — about 88% occupied, or roughly 7 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above 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 3.19 hrs/resident/day on weekends vs 3.91 on weekdays — 18% thinner on weekends. RN hours go from 1.09 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

9
deficiencies at the latest standard inspection (2026-03-20)
7
at the previous standard inspection (2025-01-16)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Actual harm · G2026-01-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one resident's (Resident #2) right to be free from physical abuse when Resident #1 slapped Resident #2 on the cheek. The facility census was 52. Review of the facility's Abuse and Neglect Policy undated., showed:- The purpose is to ensure that the residents of Morningside Center are protected from any mistreatment, neglect or all types of abuse;- Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse;- Abusers may include facility staff, other residents;- Abuse is defined as any verbal, mental, sexual, physical mistreatment of a resident whether or not an actual injury occurs;- Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-03-20 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor 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 interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for Resident #29, Resident #13 and Resident #21 were correct when the Durable Power of Attorney's (DPOA) a legal document that authorizes a designee to manage financial or medical affairs if the person became incapacitated, name was printed on the DNR instead of the name of the resident on Resident #29's DNR, and when the facility failed to ensure that two residents (Resident #13 and Resident #21) had physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. This affected three of 14 sampled residents (Resident #29, Resident #13 and Resident #21). The facility census was 56. The facility did not provide the requested code status policy.1. Review of Resident #29's Quarterly Minimum 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-20 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 resident assessments were completed accurately for two of 14 sampled residents (Resident #1 and Resident #7) when the facility failed to accurately document a diagnosis of Resident #1 and failed to accurately document a Urinary Tract Infection (UTI) for Resident #7. The facility census was 56.The facility did not provide a resident assessment or Minimum Data Set (MDS) policy. MDS is a federally mandated assessment completed by facility staff in accordance with specified formats and timelines in conducting comprehensive assessments as part of an ongoing process through which the facility identifies preferences and goals of care, functional and health status, strengths and needs. 1. Review of Resident #1's Quarterly MDS, a federally mandated assessment completed by facility staff, dated 02/03/26, showed:-Resident had no cognitive impairment;-Diagnoses included high blood pressure and kidney failure;-Chronic Obstructive Pulmonary Disease (COPD) 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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 comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. When facility staff did not address UTI (urinary tract infection) with antibiotic usage for two residents (Resident #25 and Resident #14), did not address use of anticoagulant medication or therapeutic activities for one resident (Resident #52) and when dementia care had not been cared planned for one resident (Resident #29 & Resident #52). This affected four of the 14 sampled residents. The facility census was 56.Review of the facility's care plan policy, updated 8/2024 showed a comprehensive, person-centered care plan will include measurable objectives and timetables to [NAME] the resident's physical, psychosocial and functional needs is developed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-20 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed ensure professional standards of quality of care and all services are provided according to accepted standards of clinical practice when licensed nursing staff administered medications without verification of the order prior to administration for two residents (Resident #1 and Resident #34) and when not maintaining proper nursing techniques and infection control measures for the removal and insertion of an indwelling urinary catheter for two residents (Resident #25 and Resident #5). The affected four residents out of the 14 sampled residents. The facility census was 56.Review of the facility's undated Catheter Insertion and Removal Policy showed: -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of meatus; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to provide complete perineal care for Residents #13, #5, #7, #50 after an incontinence episode. This affected four of 14 sampled residents. The facility census was 56. Review of the facility's Perineal Care policy dated 2024 showed:-This procedure provides cleanliness and comfort to the resident and prevents infections;-Review the resident's care plan for any special needs of the resident;-Assemble any special supplies that are needed;-Use personal protective equipment;-Wipe from front to back cleaning all areas that urine and feces have touched;-Document how the resident tolerated the procedure and if the resident refused care;-Report any other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #13's admission…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that two residents (Resident #5 & #25) who had urinary catheter (a tube inserted into the bladder to drain urine from the body), received appropriate treatment and services to prevent urinary tract infections when the facility failed to provide proper catheter care management. The affected two of the sampled 14 residents. The facility census was 56Review of the facility's undated Catheter Insertion and Removal Policy showed: -To remove catheter: put on disposable gloves, attach syringe to balloon port of catheter and aspirate entire amount of sterile water in balloon; -Pinch catheter and withdraw gently and slowly; -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of urinary opening; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward and discard;-Insert…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). When staff failed to verify a physician's order prior to the administration of insulin and narcotic medications resulting in two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected two of the 14 sampled residents, (Resident #1 and #34). The facility census was 56.Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so;- Personnel authorized to administer medications do so only after they have familiarized themselves with the medication;- Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR)/eMAR (electronic MAR) is compared with the medication label;- Information on the medication should be checked against the MAR/eMAR…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-20 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 and interview the facility failed to ensure that two residents (Resident #1, and Resident # 34) were free from significant medication errors when RN B failed to verify an insulin and narcotic order prior to the administration of both, placing both residents at risk for negative outcome to their health and safety. This affected two residents out of 25 possibilities for a significant medication order. The facility census was 56. The facility was unable to provide any policy regarding a significant medication error. 1. Review of Resident #1's admission baseline care plan showed the resident was alert and oriented with cognition intact and a recent re-admission to the facility. The resident was an insulin dependent diabetic and took insulin with all meals. Record review showed the resident had a current physician's order for Lispro Insulin injection of 100 units per milliliter (ml) and orders to have 3ml subcutaneous (fatty layer of tissue between the skin and muscle) with meals. Order began on 1/16/2026 Observation on March 19, 2026 at 11:56 A.M. , showed RN B at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when the facility staff failed to maintain sterile precautions when placing a urinary catheter (a tube placed in the bladder to drain urine) for one Residents (Residents #5) out of the 14 sampled residents, and additionally when dietary staff failed to wash hands when serving water on 300 hall without performing hand hygiene between dirty and clean tasks. The facility census was 56.Review of the facility's undated Catheter Insertion and Removal Policy showed: -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of meatus; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward and discard;-Insert catheter into meatus at an upward angle; -Give peri-care and leave resident clean 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to assure staff treated residents in a manner that maintained their dignity when staff failed to respond to call lights in a timely manner which affected six of the 13 sampled residents, (Resident #15, #47, #45, #1, #27 and #53. The facility census was 52. Review of the facility's policy titled, Residents Call System, revised September 2022, showed: - Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station; - Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; - Calls for assistance are answered as soon as possible, but no later than five minutes; - Urgent requests for assistance are addressed immediately. Review of the facility's policy titles, Answering the Call light, dated 2001, showed: - The purpose of this procedure is to ensure timely…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2025-01-16 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to follow up with resident's grievances regarding quality of life and resident care or then they did not provide a rationale or response to resident council. This had the potential to affect all the residents at the facility. The facility census was 52. Review of the facility's Grievance Policy, dated 1/1/24 showed: -All grievances would be handled promptly and according to federal regulations; -Provide a written response to the complaint, including: a summary of findings, actions taken or planned to resolve the grievance; -Conduct follow-up with the complainant to ensure satisfaction with the resolution; -All staff will receive training on residents' grievance rights and this policy during orientation and annually thereafter. Review of resident council minutes dated 9/24/24, 10/29/24, and 12/31/24 showed: -No reference to prior months concerns; -No documented resolutions for residents' past concerns; -No documented explanation of why ongoing concerns were not be addressed. During a group interview on 1/14/25 at 2:11 P.M.,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0678 — failed to provide CPR when needed — pattern
    Provide 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 interviews and record review, the facility failed to obtain a physician's order for code status for four residents (Residents #26, #22, #51, and #16) out of the 13 sampled residents. The facility census was 52. A policy and procedure regarding the provisions of basic life support was requested, but not provided. The physician services policy, date 8/2024., shows once a resident is admitted to the facility, orders for the resident's immediate care and needs can by provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 1. Review of Resident #26's face sheet showed: -readmission on [DATE]; -Diagnoses: Dementia, heart disease, arthritis, fracture of right leg; -Code Status -Do Not Resuscitate (No life saving measures); -Assistance with all activities of daily living. Review of the care plan, last updated 8/14/24., showed there was no code status listed in the care plan. Review of the physician orders from readmission date of 2/7/2024 through January 2025., showed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed for follow infection control guidelines when they allowed four volunteers #1, #2, #3, and #4 to be around and provide services in the facility for residents before completing any TB skin testing. This had the potential to affect all residents. The facility census was 52. Review of the facility's undated TB (Tuberculosis) skin test., showed: -The purpose of a TB skin test is to determine if a resident or employee has been exposed to tuberculosis. -TB test will be done on all new employee at the time of hire and three weeks later. -The policy does not address TB skin testing for volunteers. Record Review of Volunteer #1., showed: - Hire date 4/24/24 -Completed criminal background checks 5/1/25 -Start date 5/1/25 -No TB skin testing was completed. Record Review of Volunteer #2., showed: -Hire date 11/4/24 -Completed criminal background checks 11/6/24 -Start date 11/6/24 -No TB skin test was completed. Record Review of Volunteer #3., showed: -Hire date 6/15/23 -Completed criminal background checks 7/14/23 -Start date 7/14/23…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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

    Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one of 13 sampled residents, when they did not care plan the dialysis needs for Resident #106. The facility census was 52. Review of the facility's Care Plan policy, date 8/2024., showed: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of Resident #106's face sheet showed and admission date of 1/10/25. Review of the resident's baseline care plan, dated 1/10/25, showed: - The resident was slightly confused; - History of falls prior to admission; - Required assistance of one staff for bed mobility, transfers, walking, toileting, and showers; - Continent of bowel and bladder; - Written summary of baseline care plan - evaluate after stroke, by therapy to restore function and potentially move to assisted living. - The baseline care plan did not address the issue of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0661 — isolated
    Ensure 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 observation, interview and record review, the facility failed to complete a discharge summary for one of 13 sampled residents (Resident #55) and additionally failed to follow their own discharge planning policy. The facility census was 52. Review of the facility's Discharge Planning Policy, effective 1/11/24, showed, - The facility is committed to ensuring that all residents experience a person-centered, safe, and coordinated discharge process. Discharge planning will prioritize residents' needs, preferences, and post-discharge care requirements while adhering to regulatory standards. -Administrator is to ensure the necessary resources and staff training for effective discharge planning. - The Social Service Designee will: 1) Initiate discharge planning upon admission and update the plan throughout the residents' stay. 2) Ensure residents and their representatives are involved in the discharge planning process; receive education about discharge options and next steps. 3) Conduct a thorough assessment of residents' needs including physical, cognitive, and psychological…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure communication between the facility staff and dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) center followed standards of practice, when staff failed to document an assessment before and after dialysis. This affected one of the 13 sampled residents (Resident #106). The facility census was 52. Review of the facility's policy titled, Peritoneal Dialysis (a treatment for kidney failure that uses the lining of the abdomen to filter blood) (Continuous Ambulatory), revised October 2010, showed: - All dialysis procedures are administered outside of the facility under a contracted dialysis facility. 1. Review of Resident #106's face sheet showed: - admission date: 1/10/25. - Diagnoses included chronic kidney disease, Stage 3 (a moderate level of kidney damage where the kidneys are not filtering waste effectively, indicated by a decreased estimated glomerular filtration rate (eGFR) between 30 and 59 ml /min.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-06-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary manner, failed to ensure food items were properly labeled and dated, failed to enter temperatures on the temperature logs and failed to ensure the walk in freezer did not have ice buildup. These all have the potential to affect all residents residing in the facility. The facility census was 55. The facility did not provide any policies. Record review of the walk in freezer temperature log showed: - No entries in the morning on 5/1, 5/7, 5/10, 5/13, 5/14, 5/19, 5/20, 5/21, 5/24, 5/25, 5/26, 5/27, 5/28 and no entries in the evening on 5/1, 5/6, 5/21, 5/29. Review of the produce/dessert refrigerator temperature log showed: - No entries in the morning on 5/1, 5/11, 5/15, 5/20, 5/21, 5/24, 5/29 and no entries in the evening on 5/1, 5/5, 5/6, 5/18, 5/21 and 5/29. Review of the undated cleaning the refrigerator and freezers schedule showed: - Refrigerator: - Daily: Take anything out that has been opened and is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-02 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that include measurable objectives and timeframe to meet the resident's needs. This affected four sampled residents (Residents#4, #23, #29 and #33) The facility census was 55. The facility did not provide a policy regarding care planning. 1. Review of Resident #29's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/31/23, showed: -The resident makes self understood and understands others. -Score of 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). The score of 3 indicates severely impaired cognition. -Diagnoses of major depressive disorder, malnutrition, anemia, history of left femur fracture. -The resident was independent with set up with activities of daily living, including bathing, dressing and personal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-02 · tag F0700 — pattern
    Try 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 assess three residents (Resident's #4, #29, and #33) for entrapment and did not complete side rail assessments at least yearly. The facility census was 55. Review of the facilty's undated Physical Restraint policy showed: -Purpose: To prevent the resident from injuring himself or others; To improve the resident's mobility and independent functions; To treat the resident's medical symptoms. -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Equipment includes side rails (bed rails). Procedure: 1: Assess resident's need for restraint use. 2: Obtain informed consent for restraint use. 3. Obtain physician's order for restraint. 4. Develop or review resident care plan for type of restraint, reason for use, alternate methods to be used…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-02 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made three medication errors out of 26 opportunities for error, resulting in a medication error rate of 11.54%. This affected two residents sampled for medication administration (Residents #17 and #28). The facility census was 55. Review of the facility's Medications Policy, dated 5/25/22, showed: - Medications are administered in accordance with prescriber's orders; - Prior to administering the medicine the individual checks the label three times to verify: o Right resident; o Right medication; o Right dosage; o Right time o Right route; o Expiration date. 1. Review of Resident #17's physician order sheet (POS), dated June 2023, showed: - Start date: 5/14/22 - Artificial Tears (eye drops used to treat dry eye) to bilateral eyes, four times a day; The order did not specify how many drops to administer to each eye; - Start date: 3/15/23 - Fluticasone (nasal spray used to treat seasonal allergies) 50 micrograms…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-02 · tag F0868 — isolated
    Have 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 interview, the facility failed to maintain quarterly quality assessment committee meetings with the required members. The facility census was 55. Review of the facility's undated Quality Assurance and Performance Improvement (QAPI) policy showed: - The Governing Body and QAA Committee of the nursing center develop a culture that involves leadership-seeking input from nursing center staff, residents, their family's and other stakeholders. - The Governing Body is responsible for the development and implementation of the QAPI program. The Governing Body is responsible for: 1. Identifying and prioritizing problems based on performance indicator data. 2. Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3. Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4. Setting clear expectations for safety, quality, rights, choice and respect. 5. Ensuring adequate resources exist to conduct QAPI efforts. -The QAA Committee reports to the executive…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
LIVINGSTON COUNTY NURSING HOME DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/22/2007
USDA RURAL DEVELOPMENTOrganization5% OR GREATER MORTGAGE INTERESTsince 01/22/2007
HUGHES, DARLENEIndividualMANAGING CONTROL - GOVERNING BODYsince 04/17/2025
JONES, CONNIEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 03/17/2016
RARDON, SHARONIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2014
THOMPSON, DEBRAIndividualMANAGING CONTROL - GOVERNING BODYsince 04/17/2025
WASHBURN, CHARLESIndividualMANAGING CONTROL - GOVERNING BODYsince 05/23/2024
WINFREY, ROBERTIndividualMANAGING CONTROL - GOVERNING BODYsince 01/22/2007
LEWIS, JODINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
MELTE, HARRI ANNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
SENSENICH, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 03/09/2020
MIDWEST PHYSICAL THERAPY PCOrganizationADP OF THE SNFsince 04/04/2013
CADY, SCOTTIndividualADP OF THE SNFsince 03/09/2025
CORBIN, LUGENISIndividualADP OF THE SNFsince 12/01/2021

CMS files one row per role, so the 20 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$5.6M
Net patient revenuemost recent cost report
-13.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 44%Medicare 6%Other / private 51%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$329per resident / day
operating cost
$10,006per month
≈ monthly operating cost
$290per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265813. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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.

What to do next