Neighborhoods Rehabilitation And Skilled Nursing B
3003 Falling Leaf Court, Columbia, MO 65201 · For profit - Corporation · 120 certified beds · (573) 256-4620 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 2 serious findings 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $85,090 in federal fines (most recent 2025-09-05)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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.
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 | 10.1% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.1% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.9% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.0% | 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 | 4.9% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.5% | 17.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 25.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 83.6% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 9.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.9% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 36.8% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 36.7% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.8% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.7% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.58 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.79 | 2.33 | 1.80 | typical |
‡ 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.
66.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 296 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.2% 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 159 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 66.6%CMS range 60.4–70.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.5–17.4 | 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 | 52.2% | 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 | 61.6% | 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 | 34.6% | 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 | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 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 | 5.1%CMS range 3.3–7.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 90.9 residents a day — about 76% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.23 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 4.87 hrs/resident/day on weekends vs 5.29 on weekdays — 8% thinner on weekends. RN hours go from 0.36 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 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to monitor one resident (Resident #1) at least every two-hours per facility policy and based on resident needs. Staff did not monitor the resident between the hours of 11:00 P.M. and 3:10 A.M. Resident #1 was found entrapped in the bedrail, face down in the mattress, unresponsive, and he/she passed away. The facility census was 89.The administrator was notified on [DATE] of Past Non-Compliance Immediate Jeopardy (IJ) which occurred on [DATE]. The Administrator immediately terminated Licensed Practical Nurse (LPN) C, suspended Certified Nursing Assistant (CNA) B pending the results of the investigation, conducted an investigation, and in-serviced all staff on rounding on [DATE]. Review of the facility's walking rounds shift report policy, undated, showed staff are directed that rounds will be made during each shift according to resident care needs and individual preferences following nursing standards of practice (typically at least every two hours…
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.
- Immediate jeopardy · J2025-09-05 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to re-assess bedrail use after a significant change in condition per policy for one resident (Resident #1). Resident #1 was found entrapped in the bedrail, found face down in the mattress and unresponsive, resulting in his/her death. The facility census was 89. The administrator was notified on 09/03/2025 of an Immediate Jeopardy which began on 08/26/2025. The IJ was removed on 09/03/2025, as confirmed by surveyor onsite verification. 1. Review of the facility's Proper Use of Bed Rails policy, undated, showed staff are to ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, or depth. Review showed responsibilities of ongoing monitoring and supervision are specified as follows:-Direct care staff will be responsible for care and treatment in accordance with the plan of care; -A nurse assigned to the resident will complete reassessments in…
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.
- Immediate jeopardy · J2025-03-31 · tag F0678 — failed to provide CPR when needed — isolatedProvide 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 interview and record review, facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for resident (Resident #1) with a signed full code physician order. The facility census is 86. The administrator was notified on [DATE] of past noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. Administration immediately in-serviced nursing staff on CPR, code status, and two-way radio communication policies. The IJ was corrected on [DATE]. Review of the facility's CPR policy, undated and reviewed/revised on [DATE], directed staff to adhere to residents' rights to formulate advance directives. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives. Review of the facility's Communication of Code status, undated, directed to follow facility policy…
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 · D2026-05-29 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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, facility staff failed to provide an appropriate emergency discharge notice to one resident (Resident #1) when staff discharged the resident to the hospital and refused to allow him/her to return to the facility. The facility census was 93.1. Review of the facilities policies did not contain a policy for emergency discharge.2. Review of Resident #1's face sheet, dated 5/29/26, showed the resident admitted to the facility on [DATE] and staff discharged him/her to the local hospital on 5/20/26.Review of the resident's progress notes, dated 5/20/26 at 11:48 A.M., showed staff documented the resident discharged back to the hospital for uncontrolled pain.Review of the resident's medical records did not contain documentation of an emergency discharge issued to the resident.During an interview on 5/29/26 at 8:47 A.M., the Director of Nursing (DON) said the facility was not informed of the full acuity of care and it was felt they could not meet the residents' needs. He/She said it 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.
- Potential for harm · Fcited before2026-01-23 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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, facility staff failed to label eye drops and nasal sprays in accordance with professional standards and failed to destroy expired medications for three medication carts and one medication room. The facility census was 88.1. Review of the facility's Medication Storage policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of eye drops or nasal sprays. Review of the facility's Administration of Eye Drops policy, dated 2001, showed the policy directed staff to label new bottles with date opened and follow facility policy or manufacturer's instructions for when to discard and replace the bottle.Review of the facility's Administration of Nasal Spray Administration policy, dated 2025, showed the policy did not contain direction or guidance for labeling or destruction of nasal sprays.2. Observation on 01/20/26 at 9:52 A.M., showed the medication cart on the [NAME] and [NAME] unit contained one opened and undated bottle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed maintain the internal temperature of hot foods held in the steamtable at a minimum of 140 degrees Fahrenheit (dF) to prevent the growth of food-borne pathogen. Facility staff also failed to ensure staff involved in food preparation and service wore effective hair restraints to prevent physical contamination of food and food contact surfaces. These failures had the potential to affect all residents. The facility census was 88.Based on observation, interview and record review, the facility staff to ensure waste containers in food preparation areas remained covered when not in use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. 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 · Fcited before2026-01-23 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 staff failed to provide Enhanced Barrier Precautions (EBP) during wound care for two (Residents #5 and #15) of five residents who had a wound and one (Resident #5) of two residents who had a catheter. The facility staff failed to provide appropriate hand hygiene between glove changes during the provision of care for one (Residents #5) of six residents. The facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for tuberculosis (TB)) was completed in accordance with their policy and on file for eight employees (Housekeeper J, Certified Medication Technician (CMT) K, Certified Nurse Aide (CNA) L, Housekeeper M, Dietary Aide (DA) N, Licensed Practical Nurse (LPN) O, Social Service Designee (SSD), and the Assistant Business Office Manager (ABOM) out of ten sampled employees. The facility census was 88.1. Review of facility's Enhanced Barrier Precautions policy, dated 2025, showed:-All staff receive training on EBP upon…
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 · E2026-01-23 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility staff failed to obtain written consent from the resident or his/her designee, guardian and conservator, or conservator to manage the personal funds of the resident in the facility resident trust account for four residents (Residents #31, #68, #121 and #122) out of nine sampled residents. Facility staff also failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds to preclude the commingling of resident funds with facility funds for one resident (Resident #124) out of two sampled residents and ensure timely refunds for five residents (Residents #121, #122, #123, #124, #125) out of six sampled discharged residents. The facility census was 88. 1. Review of the facility's policy titled, Resident Personal Fund, revised 01/05/25, showed: -If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds 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 · E2026-01-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a person-centered care plan to included behavioral interventions and activity preferences for three of three sampled residents (Resident #2, #5 and #9) who resided on a secured memory care unit. The facility census was 88. 1. Review of the facility's Dementia Care policy, dated 2025, showed individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. Review of the facility's Activity policy, dated 2026, showed it is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Special considerations will be made for developing meaningful activities for residents with dementia.…
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 · E2026-01-23 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to review and revise the comprehensive care plan for three of three sampled residents (Resident #2, #6, and #9) who had falls and failed to update the care plan for one resident (Resident #5) of two sampled residents with pressure ulcers (wound created from pressure). The facility census was 88.Review of the Comprehensive Care Plan policy, dated 2025, showed the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 1. Review of Resident #2's Significant Change of Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as:-Cognitively impaired:-Needed some help with functional cognition;-Had impaired range of motion in one upper and one lower…
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 before2026-01-23 · 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 observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for catheter use and indication, catheter size and bulb size for catheters on two of two sampled residents (Resident #8 and #111) and failed to document and obtain orders for dialysis to include days of week, location of clinic, and indication for two of two residents (Resident #2 and #5) who received dialysis. The facility census was 88.1. Review of the facility's Catheter Care policy, undated, showed the policy did not contain direction or guidance for contents of a physician order for catheters. 2. Review of Resident #2's Significant Change of Status (SCS) Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/07/25, showed staff assessed the resident as: -Cognitively impaired;-Indwelling catheter;-Diagnosis of Dementia. Review of the residents Physician Order Sheet (POS), dated 01/22/26, showed: -Catheter care every shift,…
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 before2025-11-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to meet professional standards of practice when facility staff failed to transcribe physician's orders for one resident (Resident #3) and failed to complete weekly skin assessments for three residents (Resident #2, #3, and #5) out of five sampled residents. The facility census was 86. 1. Review of the facilities Physician Orders policy, undated, showed staff are directed as follows:-All physicians orders should be carried out as ordered upon the signed order of a person lawfully authorized to prescribe;-Each order should be noted and processed according to the standards of practice;-The order will be input into the electronic medical record system and then will populate into the proper areas for administration. 2. Review of Resident #3's Significant Chage Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff assessed the resident with severe cognitive impairment. Review of the resident's care plan, revised 11/03/25,…
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 before2025-04-15 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to meet professional standards when staff failed to transcribe wound care orders for two resident's (Resident #3 and #4) who had wounds. Facility staff failed to document they provided wound care as ordered for one resident (Resident #4) of one sampled resident. The Facility's censes was 90. 1. Review of the Facility's Consulting Physician/Practitioner Orders policy, undated, showed: -Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: wound clinic physician and Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians; -For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: document the verification…
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 13 citations
- Potential for harm · Dcited before2025-04-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during wound care, failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for one resident (Resident #4) with wounds out of one sampled residents. The facility's census was 90. 1. Review of the Facility's Hand Hygiene policy, undated, showed staff are directed as follows: -All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; -Hand Hygiene Table: Use alcohol based hand rub, between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE), including…
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 · D2025-03-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to report to the Department of Health and Senior Services (DHSS) neglect of one resident (Resident #1), when facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for the resident with a signed full code physician order. The facility's census was 86. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, undated, showed staff are directed as follows: -Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; -The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law; -The facility will report all alleged violations to the state agency within specified time frames: immediately, but not later…
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 before2024-11-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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, interviews, and record review, facility staff failed to store medications in a safe and effective manner in three medication rooms and one medication cart. The facility census was 91. 1. Review of the facility's Medication Storage policy, undated, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation moisture control, and security. 2. Observation on 11/12/24 at 4:08 P.M., the Booneslick hall medication room contained: -One 10 inch medical tubing with the expiration date of 04/17/23; -One three mililiter (ml) needleless syringe with an expiration date of 07/31/22. 3. Observation on 11/12/24 at 4:10 P.M., showed the Smithton Village hall medication room contained one topical antiseptic bottle with an expiration date of October 2024. 4. Observation on 11/14/24 at 2:00 P.M., showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-15 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility staff failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 91. 1. Review of the facility's Call lights: Accessibility and Timely Response policy, undated, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 2. Review of room [ROOM NUMBER], Bed 2's the electronic call light report showed: -On 11/06/24 at 9:47 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 10:43 A.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 1:01 P.M., room [ROOM NUMBER], Bed 2 alerted staff nine times before it automactically shut off after 45 minutes; -On 11/06/24 at 6:42 P.M., room [ROOM NUMBER] Bed 2 alerted staff nine times before it…
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 before2024-11-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, staff failed to maintain a professional standard of care when staff failed to document follow-up when a medication unavailable, document physician notification when the medication unavailable, and document any adverse effects from lack of medication administration for one (Resident #36) out of five sampled residents. The facility census was 91. 1. Review of the facility's Medication Error policy, dated 2024, showed: -The facility shall ensure medications will be administered according the physician orders and in accordance with accepted standards and principles which apply to professionals providing services; -Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following: Resident's condition, drug category, or frequency of error (if an error occurring repeatedly such as an omission of a resident's medication several times); -The facility will consider factors indicating errors in medication administration,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility staff failed to allow sanitized kitchenware to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. This includes three additional kitchenettes. Facility staff also failed to maintain the kitchen ceiling free from flaking paint and dry wall tape to prevent potential food contamination. The facility census was 86. 1. Review of the facility's Dietary Cleaning Procedure policy, undated, showed staff are instructed as follows: -Keep floor of kitchen free of debris; -Wet or damp dishes or tableware will be allowed to dry completely before setting table or using; -Staff will use a clean as you go technique to keep the facility and neighborhood kitchen areas clean, functional and attractive. 2. Observation on 10/23/23 at 10:52 A.M., during initial kitchen tour, showed visible buildup of crumbs and debris across the pantry floor. Observation on 10/24/23 at 9:20 A.M., of the main kitchen showed: -Visible buildup of crumbs and debris across the pantry floor; -Visible buildup of crumbs and debris…
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 · E2023-10-27 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect seven residents' privacy (Residents #22, #68, #244, #245, #247, #345 and #500). The facility census was 86. 1. Review of the facility's Notice of Privacy Practices Policy, undated, directed staff as follows: -This facility is required by the privacy regulations issued in the Health Insurance Portability and Accountability Act of 1996 (HIPPA) to maintain the privacy of each of our elder's medical information and to provide elders with notice of the facility legal duties and privacy practices with respect to each elder's information. Protecting the confidentiality of each elder's personal information has been, and always will be, a top priority for this facility; -All staff members are trained to protect all health information and keep information confidential. Review of the facility's Administering Medications Policy, revised April 2019, showed the medication cart and/or Medication Administration Record (MAR) must be clearly visible to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel eight residents (Resident #1, #15, #17, #49, #56, #65, #77, and #80) in wheelchairs in a manner to prevent accidents, failed to properly store razors/sharps for four residents (Resident #47, #54, #56 #73), failed to properly store medications for one resident (Resident #61), failed to lock medication/treatment cart when not in eyesight, and failed to store medications properly when they left insulin pens unattended on top of medication carts. The facility census was 86. 1. Review of the facility's Wheelchair Mobility policy, dated 2023, showed staff were directed to do the following: -If resident wants staff to propel them and is able to hold legs up for short distance, staff can slowly propel and assist resident with mobility as requested; -If resident needs to be propelled and does not generally move or propel wheelchair on their…
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 · E2023-10-27 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 staff failed to ensure a medication error rate of less than 5%. Out of 37 opportunities, five errors occurred, with two residents (Resident #1 and #31) resulting in a medication error rate of 13.51%. The facility census was 86. 1. Review of the facility's Medication Administration Schedule policy, revised [DATE], showed routine schedule for medications administration was every morning from 8:00-9:00 A.M. Review of the Medication Administration policy, undated, showed staff were directed to do the following: -Provide privacy; -Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, form, dose, route, and time; -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician; -Identify expiration date. If expired, notify nurse manager. 2. Review of Resident #1's MAR showed an order for the following medications: -Risperidone (used to treat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to provide appropriate catheter care, hand hygiene, and glove changes for two resident's (Resident #5, and #28), and failed to prevent one resident's (Resident #28) catheter tubing from touching the ground. 1. Review of the facility's Catheter Care policy, showed staff are directed as follows: -Catheter care will be performed every shift as needed by nursing personnel; -Ensure drainage bag is located below the level of the bladder to discourage backflow of urine; -Document care and report any concerns noted to the nurse on duty. Female: -Use a new part of the cloth or different cloth for each side; -With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Review of the facility's Hand Hygiene…
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 · D2023-10-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of 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, facility staff failed to provide reasonable accommodations to meet the needs of the residents by failing to keep the call lights within reach for four residents (Resident #8, #9, #10 and #80). The facility census was 86. 1. Review of facility's Call Light: accessibility and timely responses Policy, undated, showed the policy instructed staff as follows: -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; -Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly; -Staff will ensure the call light is within reach of resident and secured as needed 2. Review of Resident #8's admission Minimum Data Set (MDS) a federally mandated…
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 · D2023-10-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident #31, and #66) received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice by failing to provide ongoing assessments of the resident's condition, and monitoring for complications before and after dialysis treatments, and provide ongoing communication and collaboration with the dialysis clinic. The facility census was 86. 1. Review of the facility's Hemodialysis policy, revised February 2023, showed staff are directed as follows: -This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis; -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 before2023-10-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 facility staff failed to store medications in a safe and effective manner for four sampled medication carts. The facility census was 86. 1. Review of the facility's Storage of Medications policy, undated, showed staff were directed as follows: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication room according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. 2. Observation on 10/23/23 at 10:41 A.M., showed the neighborhood [NAME] and Clark's medication cart contained the following: -One loose half white pill; -One loose white pill; -One loose red pill. 3. Observation on 10/23/23 at 10:49 A.M., showed the neighborhood Flatbranch medication cart contained two loose white pills. 4. Observation on 10/23/23 at 10:53 A.M., showed the neighborhood Smithon Village medication cart…
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
$85,090 in federal fines across 2 penalties.
- $68,105 — penalty dated 2025-09-05
- $16,985 — penalty dated 2025-03-31
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 AMERICARE SENIOR LIVING — 23 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 | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 3 of 5 | 3.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 22 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MONTGOMERY, ANNA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 01/01/2013 |
| MONTGOMERY, RICHARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 06/01/2011 |
| SCHADE, KYLE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/01/2021 |
| BYERGO, LISA | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2021 |
| AMERICARE SYSTEMS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2011 |
| R H MONTGOMERY PROPERTIES, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2011 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 265840. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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 →
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