Clinton Healthcare And Rehabilitation Center
1009 East Ohio, Clinton, MO 64735 · For profit - Corporation · 120 certified beds · (660) 885-5571 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $83,041 in federal fines (most recent 2025-02-10)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (82%) runs well above the national median (45%)
- about 31% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 37.7% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.6% | 5.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.6% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.5% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 11.0% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.2% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 50.0% | 17.4% | 16.1% | check this† — see note marked dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 44.3% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.7% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.2% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.9% | 63.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.0% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.0% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.60 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.51 | 2.33 | 1.80 | worse |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
56.7% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 15.4% 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 26 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.7%CMS range 44.3–66.7 | 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 | 10.8%CMS range 7.5–14.2 | 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 | 15.4% | 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 | 30.8% | 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 | 15.4% | 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 | 72.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.8% | 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 | 0.0% | 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 | 7.3%CMS range 4.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 120 beds and averages 70.0 residents a day — about 58% occupied, or roughly 50 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 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 3.13 hrs/resident/day on weekends vs 3.75 on weekdays — 17% thinner on weekends. RN hours go from 0.23 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 82% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2025-02-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to transcribe new admission orders correctly for one resident (Resident #1) resulting in staff administering two medications in excess of the ordered dosage amounts for five days. Once notified of the error, the staff did not document notification of the physician of the medication error to obtain further direction. The resident passed away on the day the medication error was discovered. The facility census was 74. The Administrator and the Corporate Nurse were notified on 02/06/25, at 4:10 P.M. of an Immediate Jeopardy (IJ) which began on 01/24/25. The IJ was removed on 02/06/25 as confirmed by surveyor onsite verification. Review of the facility policy titled Administering Medications, dated April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing (DON) services supervises and directs 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 · Ecited before2025-03-26 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-26 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special…
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 · F2025-02-10 · tag F0843 — widespreadHave an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
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 a written transfer agreement with a hospital was in effect to ensure residents timely admission to the hospital when medically appropriate and that information would be exchanged between providers. This has the potential to effect all the residents. The facility census was 74. Review showed the facility did not provide a policy pertaining to written transfer agreements with a hospital or a written transfer agreement with a community hospital. During interviews on 02/10/25, at 1:30 P.M. and 2:10 P.M., the Regional Director of Operations said he/she was not aware of the federal requirement for the facility to have a written transfer agreement with a hospital. Staff could not locate a written transfer agreement with a hospital. During an interview on 02/10/25, at 2:00 P.M., the Regional Nurse Consultant (RNC) said he/she was unaware of the federal requirement for a written transfer agreement with one or more hospitals. The RNC said the facility made a determination on which hospital to send a resident to based on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-10 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 07/22/20; -Diagnoses included multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-10 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility,…
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 · D2025-02-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide care that met professional standards quality for one resident (Resident #2) from a sample of 13 residents. Facility staff failed to accurately transcribe the resident's physician orders on admission. The facility census was 74. Review of the facility policy titled Administering Medications, dated April 2019, showed the following: -The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions; -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns; -Each nurses' station has a current Physician's Desk Reference (PDR -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-17 · 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
Based on interview and record review, the facility failed to maintain an effective infection control program including screening all staff for tuberculosis (TB - a contagious infection that usually attacks the lungs) as required when the facility failed to ensure the first and second step of the two-step tuberculin skin test (TST) was completed prior resident contact for three staff members (Registered Nurse (RN) A, Certified Medication Tech (CMT) B, and Licensed Practical Nurse (LPN) C), failed to ensure the TB test was read within 48 to 72 hours from placement for one staff (CMT B), and failed to complete a second step TB test for one staff (RN A), of 10 sampled staff members. The facility census was 67. Review of the facility policy Employee Screening for Tuberculosis, dated March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI - infected with TB but not active TB) and active tuberculosis disease, using tuberculin skin test or interferon gamma release assay (IGRA - blood test to determine if exposed to TB) and symptom screening…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-05 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement an effective grievance process when staff failed to ensure all grievances included documentation of a full investigation, of a final decision, and of follow-up regarding findings with the resident who filed the grievance. Review of the facility policy Grievances/Complaints, Recording and Investigating, dated 2021, showed the following: -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. -The investigation and report will include the circumstances surrounding the alleged incident, the names of any witnesses and their accounts of the alleged incident, the resident's account of the alleged incident, and recommendations for corrective action. 1. Review of the Grievance/Complaint Report, dated 04/29/24, showed the following: -Resident stated the night shift Certified Nurse Aide (CNA) 4 was rough when doing cares and transfers. -Staff spoke to CNA 4 about his/her behavior and educated him/her on customer service. CNA 4 with issues at home. Explained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-05 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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, interview, and record review, interview, the facility failed to develop and implement complete and accurate care plans for all residents when staff failed to ensure five residents' (Resident #36, #42, #3, #1, and #4), of 27 residents reviewed, care plans addressed all appropriate care areas. Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated 03/2022, showed the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive person-centered care plan included measurable objectives and timeframes, resident's stated goals upon admission, and desired outcome. 1. Review of Resident #36's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 03/01/24; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-05 · tag F0697 — failed to manage pain — patternProvide 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
Based on record review and interview, the facility failed to provide effective pain management for all residents when the facility failed to ensure four of four residents (Resident #57, #32, #18 and #7) had pain medication available to be administered as ordered at all times. Review of the facility policy titled, Pharmacy and Medication Administration, undated, showed the following: -The emergency medication kit is refilled by the pharmacy; -The facility will have a clear practice about reordering of medication. lf the medication nurse or CMT (Certified Medication Tech) does not pull the labels to reorder the medications during their med pass, they may not be available when needed. Review of the facility policy titled, Emergency Kit System/With Controlled Substances (E-Kit), dated March 2015, showed the following: -The E-kit will be replaced after it has been opened and the pharmacy notified. -Replacement of the entire E-Kit will be done on the next scheduled delivery. -Remove the item/s needed. Remove enough of the medication to last until the order is filled and can be delivered.…
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 20 citations
- Potential for harm · E2024-09-05 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a system was in place to account for all controlled drugs and that allowed for accurate reconciliation when staff failed to routinely complete a documented narcotic count for each change of shift. 1. Review of the 200 Hall Narcotic Record Books, reviewed with Licensed Practical Nurse (LPN) 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/21/24 for 6:00 P.M. outgoing; -On 08/26/24 for 6:00 P.M. outgoing; -On 08/27/24 for 6:00 P.M. outgoing; -On 09/01/24 for 6:00 A.M. incoming; -On 09/01/24 for 6:00 P.M. outgoing. Review of the medication tech 100 Hall Narcotic Record Books, reviewed with LPN 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/20/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 P.M. outgoing; -On 08/26/24 for 10:00 A.M. incoming; -On 08/26/24 for 10:00 P.M. outgoing; -On 08/27/24 for 6:00 A.M. incoming; -On 08/27/24 for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-05 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a system in place to monitor for side effects and targeted behaviors for five of five sampled residents (Resident #48, #36, #42, #4, and #3) reviewed for unnecessary medications who received psychotropic medications. Review of the facility's Psychotropic Medication Use policy, dated 7/2022, showed the following: -Psychotropic medication management included .adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences. 1. Review of Resident #48's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 11/28/23; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety disorder, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · 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 ensure all residents, or resident representatives, received written notice of transfer when staff failed to provide a written notice of discharge to one resident (Resident #56), of one sampled resident, or his/her representative, for a facility initiated emergent hospital transfers. Review of the facility's Discharge Policy, dated 2021, showed the policy did not address written transfers notice. 1. Review of Resident #56's face sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 06/27/24; -Diagnoses included chronic respiratory failure with hypoxia (low oxygen levels). Review of the resident's Progress Note, located in the EMR under the Progress Note tab, showed the following: -The resident was sent to the emergency room for increased anxiety, complaints of extreme back pain, and difficulty with breathing. -The resident was admitted to the Intensive Care Unit (ICU) for chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level l assessment was submitted after a new mental illness diagnosis for two (Resident #20 and #42) out of five residents reviewed for PASARR. 1. Review of Resident #20's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 10/09/18; -readmission date of 04/19/24; -Diagnoses included unspecified mood affective disorder (mental disorder characterized by dramatic changes or extremes of mood) and major depressive disorder. Review of the resident's PASARR Level l, located under the Diagnosis tab in the EMR and dated 05/14/20, showed no mental illness diagnosis. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 05/01/24 and located under the MDS tab of the EMR, showed the resident had no cognitive impairment and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a baseline complete care plan was developed and provided for one resident (Resident #123), of 27 sampled residents, when the facility failed to care plan for the resident's diagnosis of schizophrenia (a mental health condition that affects how people think, feel and behave). Review of the facility's policy titled, Care Plans - Baseline, revised 03/2022, showed the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission; -The baseline care plan included instructions needed to provide effective, person -centered care of the resident and must include the minimum healthcare information necessary to properly care for the resident including physician orders. 1. Review of Resident #123's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 08/29/24; -Diagnoses of included schizophrenia. Review of the resident's medical record showed staff did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure all residents received respiratory care by standards of practice when staff failed to change one resident's (Resident # 4), out of 27 sampled residents, nebulizer tubing as ordered. 1. Review of the Resident #4's admission Record, found in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 09/07/19; -Diagnoses included COPD (chronic obstructive pulmonary disease - a common lung disease causing restricted airflow and breathing problems), asthma, and allergic rhinitis. Review of the resident's Respiratory Care Plan, in the EMR under the Care Plan tab, dated 03/14/24, showed the following interventions: -Administer respiratory medication as ordered. -The resident did not like to keep nebulizer mask in plastic bag and will often take it out and sit it on top of the machine. Review of the resident's Physician's Order, dated 07/27/24, and in the EMR under the Orders tab, showed the following: -An order, dated 08/23/24, for nebulizer tubing to be changed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 interview and record review, the facility failed to ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services were provided per standards of practice and resident's care plan when staff failed to have ongoing pre and post dialysis communication for one resident (Resident #38) who received dialysis. 1. Review of Resident #38's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following : -admission date of 12/05/19; -readmission date of 07/16/24; -Diagnoses included end stage renal disease (ESRD). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 07/23/24, located under the MDS tab of the EMR, showed the following: -The resident had severe cognitive impairment. -The resident received hemodialysis treatment (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately).…
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 · E2023-01-06 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
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 three nursing assistants (Nurse Aide (NA) A, NA B, and NA C) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. The facility's census was 61. Review of a facility policy entitled Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Nurse aides must undergo a state-approved training program; -The facility will not use any individual as a nurse aide who has worked less than four months unless the individual is a full-time employee and participating in a state-approved training and competency evaluation program; or has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; or has been determined competent as provided in section 483.150(a) and (b) of the requirements of participation; -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, otherwise,…
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 · D2023-01-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed) for one resident (Resident # 61). The facility census was 61. Record review of the Central Office Medical Review Unit (COMRU) instructional guide, updated October 2021, showed the PASARR is a federally mandated screening process for individuals with serious mental illness and /or intellectual or developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. The screening process assures appropriate placement of person known to suspected of having mental impairment and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment. 1. Record review of Resident #61's face sheet (a document that gives a resident's information at a quick…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks to provide effective person centered care that met professional standards of quality care when staff did not address dialysis (a procedure to remove waist products and excess fluid from the blood when the kidneys stop working) port care and monitoring before and after dialysis for one resident (Resident #219) and did not address use of a bilevel positive airway pressure (BIPAP) machine (a devise to provide air pressure for breathing in and breathing out during sleep) for one resident (Resident #222). The facility had a census of 61. Record review of the facility's policy titled Care Plans-Baseline, dated March 2022, showed the following: -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident; -The base line care plan must include minimum health care information necessary to properly care for the resident; -The base line care plan is used until…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to obtain a physician's order and provide proper cleaning and maintenance for a Bilevel Positive Airway Pressure machine (BIPAP- a devise to provide air pressure for breathing in and breathing out during sleep) for one resident (Resident #222). The facility census was 61. Record review of the facility's policy titled CPAP/BIPAP Support, dated March 2015, showed the following: -Purpose is to administer positive airway pressure to maintain open an airway; -Use to improve arterial oxygenation in residents with respiratory insufficiency; -Review the physician's order to determine the oxygen concentration and flow and the pressure for the machine; -Follow the manufacture's instructions for machine set up, delivery, and care. Record review of the Trilogy 100-BIPAP clinical manual, dated October 2018, showed the following: -The BIPAP is designed to be used by trained and qualified caregivers under the supervision of a physician; -The prescription and other devise settings should only be changed on the orders of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 observation, interview, and record review, the facility failed to provide thorough assessments and provide monitoring of the resident's dialysis central venous catheter (an intravenous line into a vein in the resident's chest), failed to maintain ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center, and failed to obtain an agreement with a dialysis provider, for one resident (Resident #219) that received dialysis. The facility census was 61. Record review of the facility's policy titled Hemodialysis Access Care, undated, showed the following: -Central Dialysis catheters must be kept clean and dry at all times; -Dressing changes should be done using sterile technique; -The nurse should document every shift, the location of the catheter, condition of the dressing, if dialysis was done during the shift, any part of report from the dialysis center nurse, and post dialysis observations. Record review of the www.mayoclinic.org website regarding hemodialysis (when a machine filters wastes, salts and fluid from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-09-13 · tag F0697 — failed to manage pain — patternProvide 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 observations, interviews, and record review, the facility failed to fully document administration and effectiveness of administered pain medications for three residents (Resident #32, #36, and #72); failed to address and notify the physician of continued pain for one (Resident #32 and #73); and failed to document administration of pain medication for one resident (Resident #36) in a sample of 18. The facility's census was 71. Record review of the facility's pain assessment and management policy, dated March 2015, showed the following: -The purposes of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -Pain management is a multidisciplinary care process that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-13 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two resident (Resident #2 and #37) who remained in the facility after discharge from Medicare Part A services. The facility census was 71. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-13 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 assess the use of a seat belt to determine if it was a restraint and obtain a physician order for use of the seatbelt for one resident (Resident #9) who was not consistently able to remove the seat belt without staff assistance. The facility census was 71. Based on the facility policy titled Physical Restraint Application, dated October 2010, showed the following: -The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints; -Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) 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; -The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has…
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 · D2019-09-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to develop a comprehensive care plan for one resident (Resident # 46) out of a sample size of 18 residents. The facility census was 71. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered dated December 2016 showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain 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 · D2019-09-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess one resident (Resident #73) for change in condition and adequately complete neurological checks (level of consciousness is evaluated) following a fall. The facility failed to assess the resident's catheter (a sterile tube inserted into the bladder to drain urine) which had blood following a fall. The facility failed to address the resident's request to be discharged to the hospital. This practice affected one resident out of a sample of 18 residents. The facility census was 71. Record review of the facility's Managing Falls and Fall Risk policy, dated March 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Resident conditions that may contribute to the risk of falls include: fever, infection, delirium and other cognitive…
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 · D2019-09-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to obtain an order for a catheter (a sterile tube inserted into the bladder to drain urine) and catheter care for one resident (Resident #46) and failed to follow orders for catheter care for another resident (Resident #56) out of sample size of 18 residents. The facility census was 71. Record review of the facility's policy titled Suprapubic Catheter (urinary bladder catheter inserted through the skin about 1 inch above the symphysis pubis (pelvis)) Care, dated October 2010, showed the following: -The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract; -Review the resident's care plan to assess for any special needs of the resident; -Wash around the catheter site with soap and water. (Note: If the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water.) Wash the outer part of the catheter tube…
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 · D2019-09-13 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 obtain a physician's admission orders in a timely manner for one resident (Resident #73) when the facility did not confirm a physician for the resident until three days later. The physician orders for the resident were signed by a physician two months later. This practice affected one resident out of a sample of 18. The facility census was 71. 1. Record review of Resident #73's face sheet (general information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included paraplegia, unspecified injury at T7-T10 level of thoracic spinal cord, and fracture of T9-T10 vertebra. Record review of the resident's hospital Discharge summary, dated [DATE], showed the following: -Diagnoses included acute pain due to trauma, traumatic epidural hematoma (brain bruise), acute kidney injury, motor vehicle collision, T 9 spinal cord injury, T 9 vertebral fracture, and acute renal failure; -Resident is alert and oriented and in no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-09-13 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 address one resident's (Resident #66) dental needs out of a sample of 18 residents in a facility with a census of 71. Record review of the facility's policy titled, Availability of Services, Dental, revised August 2007, showed the following information: -Oral healthcare and dental services will provided to each resident; -Dental services are available to all residents requiring routine and emergency dental care; -All requests for routine and emergency dental services should be directed to Social Services and/or designee to assure that appointments can be made in a timely manner; -Residents with lost or damaged dentures will be promptly referred to a dentist. Record review of the facility's policy titled Routine Dental Care, revised April 2007, showed the following information: -Each resident will receive routine dental care; -The attending physician will be notified of a resident's need for dental treatment and order dental consultations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$83,041 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $83,041 — penalty dated 2025-02-10
- Medicare payment denial — starting 2025-03-20 for 25 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CIRCLE B ENTERPRISES — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.5 | -1.5 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 1 of 5 | 2.0 | -1.0 vs chain |
| Quality measures | 1 of 5 | 1.9 | -0.9 vs chain |
The other 35 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CLINTON EXEMPT TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | 100% | since 04/23/2004 |
| BEDELL, DONALD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/23/2004 |
| BEAIRD, TODD | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| AGH1 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2025 |
| SOVEREIGN HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/06/2025 |
| FOSTER, GEORGANN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/29/2025 |
| SNELL, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2001 |
| BEDELL, BRYAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/28/2025 |
| CLINTON RE LLC | Organization | ADP OF THE SNF | — | since 03/12/2013 |
| DCB REAL ESTATE PARTNERSHIP LP | Organization | ADP OF THE SNF | — | since 03/12/2013 |
| FG LLC | Organization | ADP OF THE SNF | — | since 12/02/2016 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 08/16/2021 |
| MID STATES INC | Organization | ADP OF THE SNF | — | since 08/15/2014 |
| VAN DE VEN LLC | Organization | ADP OF THE SNF | — | since 01/01/2000 |
CMS files one row per role, so the 22 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 31% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265255. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-05, 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.