Community Manor
783 Weber Road, Farmington, MO 63640 · For profit - Limited Liability company · 99 certified beds · (573) 756-8998 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2026
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
- about 23% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.6% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.0% | 2.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.8% | 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 | 7.5% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.0% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 35.0% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 88.7% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 21.8% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.0% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.2% | 13.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.11 | 2.33 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.2% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% 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 | 42.2%CMS range 28.8–58.3 | 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 | 11.4%CMS range 8.6–15.5 | 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 | 53.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 75.0% | 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 | 53.6% | 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 | 98.0% | 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 | 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 | 0.0% | 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 | 2.0% | 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 | 7.6%CMS range 4.0–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 99 beds and averages 94.9 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.43 hrs/resident/day on weekends vs 3.11 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 1 administrator has left in the past year.
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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · D2026-06-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the misappropriation of two gift cards from one resident (Resident #1) out of a sample of five residents when a staff member took possession of the resident's $200 Amazon gift card and $300 Visa gift card. The facility census was 98.The administration was notified on 06/04/26 of the Past Non-Compliance which occurred between 05/29/26 through 06/01/26. On 06/01/26, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 06/01/26, as the facility completed disciplinary action for CNA A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated.Review of the facility's policy titled, Abuse Prevention Program, revised April 2021, showed:-Misappropriation of resident property defined as deliberate misplacement,…
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 · D2026-03-12 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds for the operating account in a timely manner for six residents (Residents #1, #2, #3, #4, #5 and #6). The facility census was 66.1. Record review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated [DATE], showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account#1 $241.00#2 $4,140.00#3 $18.00#4 $6,902.43#5 $4,420.00#6 $1,205.00Total $16,926.43 Record review of the facility-maintained paperwork showed Residents #1, #2, #3, #4 and #5 expired and Resident #6 discharged on the following dates:Number Discharge/ Expire Date#1 [DATE]#2 [DATE]#3 [DATE]#4 [DATE]#5 [DATE]#6 [DATE] Record review showed the facility did not provide the Personal Fund Account Balance Report (TPL) to the Missouri…
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 before2025-06-06 · 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 interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents (Resident #25 and #77) out of three sampled residents who were discharged from Medicare Part A services with benefit days remaining. The facility's census was 97. The facility did not provide a policy for SNF ABN or NOMNC forms. 1. Review of Resident #25's medical record showed: - The resident discharged from Medicare Part A services on 02/28/25; - The resident remained in the facility; - The facility failed to issue a NOMNC to the resident. 2. Review of Resident #77's medical record showed: - The resident discharged from Medicare Part A services on 04/30/25; - The resident remained in the facility; - The facility failed to issue a SNF ABN to the resident. During an interview on 06/05/25 at 2:29 P.M., the Social Services Designee (SSD) said she hasn't gotten this process down to a science. She said she was told by corporate to use these two forms, and pointed to two ABN forms - one dated…
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 · D2025-06-06 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital for four residents (Resident #15, #23, #49, and #67) out of 20 sampled residents and failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #49, and #67) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy, Bed-Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for one resident (Resident #23) out of 20 sampled residents and two residents (Resident #31 and #60) outside the sample. The facility's census was 97. Review of the facility's policy, Resident Assessments, revised October 2023, showed: - A comprehensive assessment of each resident is completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act of 1987 are comprehensive evaluations of a resident's needs and condition within a nursing home, conducted by the facility staff) regulations and PPS (Prospective Payment System-a method of healthcare reimbursement where the Centers for Medicare and Medicaid Services (CMS) pays a provider a fixed amount based on the type of service rendered) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES-cloud based application developed by CMS to help measure and evaluate the quality of care for Medicare and Medicaid…
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 · D2025-06-06 · 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 interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for three residents (Resident #6, #48, and #85) out of 20 sampled residents. The facility's census was 97. Review of the facility's Comprehensive Person-Centered Care Plan policy, revised March 2022, showed: - A comprehensive, person-centered plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial, and functional needs will be 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 comprehensive, person-centered care plan is developed within seven days of completion of the required Minimum Data Set (MDS-a federally mandated assessment, completed by facility staff), and no more than 21 days after admission; - The care plan interventions…
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 before2025-06-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and/or follow physician orders in a timely manner after the pharmacist made recommendations for specific medications for one resident (Resident #31) outside of the 20 sampled residents and failed to ensure a Certified Nursing Assistant (CNA) did not perform duties outside the scope of practice. The facility's census was 97. Review of the facility's Medication Regimen Reviews (MRR) policy, revised May 2019, showed: - The consultant pharmacist reviews the medication regimen of each resident, at least monthly; - The goal of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication; - The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities; - Within 24 hours of the MRR, the consultant pharmacist provides a written report to attending physicians for each resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #15) out of one sampled resident. The facility's census was 97. Review of the facility's policy, Suctioning the Trachestomy Tube, revised October 2023, showed: - The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract; - Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning; Review the resident's care plan to assess for any special needs of the resident; Obtain baseline vital signs and oxygen saturation; Obtain information about the resident's medical history, including date of tracheostomy, respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive…
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 before2025-06-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain correct orders from the physician for dialysis (a process for removing waste and excess water from the blood) care, specifically for a port access (a medical device implanted for easy access to a vein), instead of a fistula (a surgically created connection between an artery and a vein, used for dialysis access) for one resident (Resident #48) out of one sampled resident. The facility's census was 97. Review of the facility's Care of a Resident With End-Stage Renal Disease (ESRD) policy, revised September 2010, showed: - Staff caring for residents with ESRD, including residents that receive dialysis care outside of the facility, shall be trained in the care and special needs of the resident; - Education and training of staff includes the nature and clinical management of ESRD, including infection prevention and nutritional needs, the type of assessment data that is to be gathered about resident's condition on a daily or per shift basis; - How to…
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 · D2025-06-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less. There were four medication errors out of 30 opportunities for errors, resulting in an error rate of 13.33%. This practice affected resident (Resident #39) out of 20 sampled residents and one resident (Resident #91) outside the sample. The facility's census was 97. Review of the facility's policy, Administering Medications, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions, and honoring resident choices and preferences, consistent with his or her care plan; - Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. Review 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.
Show the remaining 20 citations
- Potential for harm · Dcited before2025-06-06 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility's census was 97. Review of the facility's Food Receiving and Storage policy, revised November 2022, showed: - Food shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in refrigerator or freezer are covered, labeled, and dated with a use by date; - Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. Review of the facility's Sanitation policy, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; - All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; - Kitchen wastes that are not disposed of by chemical means…
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 before2025-06-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to keep a urinary catheter drainage bag off the floor for one resident (Resident #15) out of 20 sampled residents. The facility failed to use enhanced barrier precautions (EBP) for one resident (Resident #39) out of 20 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection during peri (washing the genital and anal areas of the body) and urinary catheter (a flexible tube that is placed to drain urine from bladder) care for two residents (Resident #47 and #75) out of 20 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection during medication administration for two residents outside the sample (Resident #91 and #246). The facility failed to maintain infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-21 · 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 and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 96. Review of the facility policy, Refrigerators and Freezers, revised November 2022, showed: - Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41° F and freezers keep frozen foods frozen solid; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken. The last column will be completed only if temperatures are not acceptable; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening; - The supervisor takes immediate action if temperatures are out of range. Actions…
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 before2024-06-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #36) out of 20 sampled residents. The facility's census was 96. Review of the facility policy, Certifying Accuracy of Resident Assessment, revised November 2019, showed: - Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge; - Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment; - The information captured on the assessment reflects the status of the resident during the observation (lookback) period for that assessment. Different items on the MDS may have different observation periods; - The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-21 · 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
Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #48) outside of the sample. The facility census was 96. Review of the facility policy titled, Medication and Treatment Orders, last revised 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; - Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis; - All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; - The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used; - The staff and practitioner shall use only approved abbreviations and symbols when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #7 and #30) out of two sampled residents. The facility census was 96. 1. Review of Resident #7's medical record showed: - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other import mental functions), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), other bilateral secondary osteoarthritis of first carpametacarpal joint (breakdown of cartilage in the joint.) Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 05/10/24, showed: - Moderately impaired cognition; - Dependent with activities of daily living (ADLs) and self care; - Impairment on one side of lower extremities; - Restorative…
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 · D2024-06-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 the Registered Dietician's (RD) recommendations for weight loss were provided to the physician which affected one resident (Resident #7) out of 20 sampled residents. The facility census was 96. Review of the facility policy, Weight Assessment and Intervention, revised March 2022, showed: - Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month - 5% weight loss is significant; greater than 5% is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe; Six months - 10% weight loss is significant; greater than 10% is severe. Review of the facility policy, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, showed the staff will report to the physician significant weight gains or losses or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-21 · 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 provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center for one resident (Resident #33) out of one sampled resident receiving dialysis. The facility census was 96. Review of the facility's policy titled, Hemodialysis Catheters-Access and Care of, dated 02/2023, showed: Care of the AVF's and AVGs: - Do not use access arm to take blood pressure; - Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals; - Check patency of the site at regular intervals. Palpate the site to feel the thrill,or use a stethoscope to hear the whoosh or bruit of blood flow through the access; - The nurse should document in the resident's medical record every shift as follows: location of catheter, condition of dressing, If dialysis was done…
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 before2024-06-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices while providing care for two residents (Resident #1 and #36) out of 20 sampled residents and failed to provide appropriate documentation of tuberculosis (TB-an infectious bacterial disease that affects the lungs) testing for five residents (Resident #12, #24, #28, #30 and #76) out of five sampled residents. The facility census was 96. Review of the facility's policy, Personal Protective Equipment-Using Gloves, last revised September 2010, showed: - Use gloves when touching excretions, secretions, blood, body fluids, or non-intact skin; - To prevent spread of infection; - To protect hands from potentially infectious material; - Wash hands after removing gloves. Review of the facility's policy, Screening Residents for Tuberculosis, last revised August 2019, showed: - The facility shall screen all residents for tuberculosis infection and disease; - Individuals identified with active TB shall 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 · Dcited before2024-04-29 · 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, record review and interview, the facility failed to notify a resident's family or next of kin for two of three sampled residents, (Residents #1 and #2) after a change in condition. The facility census was 98. 1. Record review of the facility policy, Change in a Resident's Condition or Status, dated February 2021 shows; Unless otherwise instructed by the resident, a nurse will notify the residents representative when; - The resident is involved in any accident or incident that results in an injury including injuries of unknown source. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 03/04/24 showed: - Diagnoses chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), diabetes Type 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia with behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-02-23 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a cover on the trash containers within the kitchen and failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpsters. This had the potential to affect all residents. The facility census was 95. 1. Observation of the kitchen on 2/19/23 at 11:40 A.M. showed the following: - One uncovered 32 gallon trash receptacle partially full of refuse near the dishwashing station; - One uncovered 32 gallon trash receptacle partially full of refuse near the food slicer; - One uncovered 32 gallon trash receptacle filled with cardboard refuse near the back kitchen exit. 2. Observation of the kitchen on 2/19/23 at 12:00 P.M. showed the following: - One uncovered 32 gallon trash receptacle partially full of refuse in the food preparation area; - One uncovered 32 gallon trash receptacle filled with cardboard refuse near the back kitchen exit; - One uncovered 32 gallon trash receptacle partially full of refuse near the dishwashing station. 3. Observation 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 before2023-02-23 · 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 interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for two residents (Resident #27 and #36) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for one resident (Resident #47) out of three sampled residents. The facility's census was 95. 1. Record review of Resident #27's NOMNC and SNF ABN forms showed: - The resident's skilled Medicare Part A services started on 11/9/22, ended on 11/22/22, and the resident remained in the facility; - The resident's representative gave…
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 · D2023-02-23 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change assessment for three residents (Resident #58, #64, and #90) out of 19 sampled residents. The facility's census was 95. Record review of the facility's policy titled, Resident Assessments, dated 11/2019, showed: - A significant change assessment is completed within 14 days of the interdisciplinary team determining that the resident meets guidelines for major improvement or decline; - The significant change assessment is required when a resident: - Enrolls in a hospice program; - Changes hospice providers and remains in the facility; - Discontinues hospice services; - Experiences a consistent pattern of changes with two or more areas of decline from baseline. 1. Record review of Resident #58's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 12/3/22, showed the resident not on hospice care. Record review of the resident's medical record showed: - admitted to hospice care on…
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 before2023-02-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) for three residents (Residents #44, #51, and #64) out of 19 sampled residents and one resident (Resident #41) outside of the sample. The facility census was 95. 1. Record review of Resident #41's annual MDS, dated [DATE], showed: - Resident on an anticoagulant. Record review of the resident's Physician Order Sheet (POS), dated 2/2023, showed: - An order, on 10/12/22, for aspirin (an antiplatelet medication that prevent blood cells from clumping together); - No order for an anticoagulant (a medication that help prevent prevent blood clots by slowing down the body's process of making clots). During an interview on 2/22/23 at 12:38 P.M., the MDS Coordinator said aspirin should not be coded as an anticoagulant. 2. Record review of Resident # 44's quarterly MDS, dated [DATE], showed: -No use of anticoagulant. Record review of the resident's…
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 · D2023-02-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #20, #29, #76, and #85) out of 19 sampled residents. The facility census was 95. Record review of the facility's 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, psychosocial and functional needs will be developed and implemented for each resident; - The care plan will be consistent with the resident rights, professional standards of practice, medical provider orders and resident's goals and preferences; - It will include measurable objectives and timeframes to meet a resident's special medical, nursing, mental and psychosocial needs that will be identified in the resident's comprehensive assessment. 1. Record review of Resident #20's medical record showed: - admitted on…
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 · D2023-02-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with personal hygiene for two residents (Resident #151 and #401) out of 19 sampled residents. The facility's census was 95. Record review of the facility's policy titled, Resident Hygiene, not dated, showed: - Staff will ensure residents are neat, clean and well groomed at all times; - Residents will be scheduled a shower/bath at least twice per week as needed; - Hair will be shampooed during shower or at the beauty shop; - Hair will be brushed/combed during AM care, after naps and as needed to maintain a neatly groomed appearance; - Oral hygiene is performed during AM care, PM care and as needed to maintain good oral hygiene; - Face and hand washing are performed during AM care, PM care, after toileting, after meal/snacks and other times as needed. 1. Record review of Resident #151's medical chart showed: - admitted on [DATE]; - Diagnoses included legally blind, seizures, and multiple sclerosis (a potentially disabling…
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 · D2023-02-23 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #29) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 19 sampled residents. The facility's census was 95. Record review of the facility's Trauma Informed Care policy, undated, showed: - Facility must ensure that trauma survivors receive trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers leading to re-traumatization; - Facility social service/interdisciplinary care team will determine through assessment upon admission, annually and as needed: * Identify cultural preferences of residents who are trauma survivors; * Identify a resident's past history of trauma; *…
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 · D2023-02-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects or warnings of those immunizations. This effected four residents (Resident #1, #31, #39, and #90) out of 19 sampled residents. The facility census was 95. Record review of the facility's policy titled, Vaccination of Residents, revised October 2019, showed: - Prior to vaccination, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations; - Provisions of such education shall be documented in the resident's medical record; - All new residents shall be assessed for current vaccination status upon admission; - The resident or legal representative may refuse vaccines for any reason; - If vaccines are refused, the refusal shall be documented in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-06-06 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in five rooms. Storing items on the overbed light creates a hazard of the items falling on resident below and does not utilize the light fixture as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility's census was 97. The facility did not provide a policy regarding overbed light safety. Observation on 06/06/25 showed: - At 6:00 P.M., room W12 with a decorative Blessed sign stretching across the light fixture; - At 6:05 P.M., room W16 with a decorative Welcome sign and paper picture of a horse on top of the light fixture; - At 6:06 P.M., room W20 with a sound bar for the television on top of the light fixture; - At 6:08 P.M., room W22 with two small decorative Christmas trees, a stuffed animal, and another small decoration on the light fixture; - At 6:30 P.M., room E11 with eight small, decorative items on the light fixture.…
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.
- No harm found · C2024-06-21 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility census was 96. The policies provided by the facility did not address who is required to attend QAPI meetings. 1. Review of the QAPI sign in sheets, provided by the Administrator, showed the Medical Director did not attend any meetings from August 2023 through May 2024. During an interview on 06/21/24 at 10:10 A.M., the Administrator said QAPI meetings are held monthly and the previous month is reviewed. The Medical Director has not attended QAPI meetings in quite some time, but she would expect him to.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SHAFIQ MALIK — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 4 of 5 | 3.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 8 homes this chain runs (chain average 3.5★, 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 | Since |
|---|---|---|---|
| MALIK, OMER | Individual | DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/28/2018 |
| MALIK, SHAFIQ | Individual | DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/28/2018 |
| PARKS, LORA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2021 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 01/01/2024 |
CMS files one row per role, so the 13 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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 265798. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-06, 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.