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

Forsyth Rehabilitation & Health Care Center

477 Coy Blvd, Forsyth, MO 65653 · For profit - Corporation · 120 certified beds · (417) 546-6337 Medicare & Medicaid certified

Call the home — (417) 546-6337 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 2023
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • a high number of inspection citations overall (25) — 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)
  • about 33% 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
256 State Highway Y · (417) 546-4200 · Call to confirm hours
Pharmacy
16269 US Highway 160 · (417) 546-5151 · Call to confirm hours
Grocery
15720 Korean War Veterans Hwy · (417) 546-2101 · Call to confirm hours
Park
164 Forsyth Taneyville Rd · (417) 546-2876 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.4%18.1%15.4%typical
Long-stay residents who lose too much weight2.2%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection2.3%2.3%2.0%worse
Long-stay residents with depressive symptoms7.9%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.9%4.1%3.3%worse
Long-stay residents whose ability to walk worsened17.1%17.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication47.8%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine93.5%90.9%95.3%typical
Long-stay residents with pressure ulcers4.6%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control26.6%17.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.1%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine77.8%63.5%79.4%typical
Short-stay residents rehospitalized after admission23.9%26.0%22.6%typical
Short-stay residents with an outpatient ER visit19.1%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.832.111.67better
Long-stay outpatient ER visits per 1,000 resident days0.812.331.80better

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

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

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

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

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

56.9% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
44.1%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 44.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.9%CMS range 45.4–72.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.4–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge44.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge91.7%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.7%CMS range 4.4–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.30
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.00
Aide hours/ resident / day
2.90
Total nurse hours/ resident / day
0.17
RN hoursweekends
36.5%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 90.8 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 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.09 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.36 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as 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

7
deficiencies at the latest standard inspection (2025-11-17)
6
at the previous standard inspection (2024-01-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Fcited before2025-11-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility failed to keep dented cans separated from other cans, when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, when the facility staff failed to ensure fans in food areas were free from dirt and debris, and when staff stacked dishes while still wet. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 93 residents.1. Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following information:-Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard;-Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food;-If the integrity of the packaging has been compromised, contaminants…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-17 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed promote each resident's right to self-determination when the facility failed to provide services to maintain good grooming and personal hygiene in accordance with resident preferences for five residents (Resident #86, #77, #84, #82, and #64). The facility census was 93.Review showed the facility did not provide a policy related to showers. 1. Review of Resident #86's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 06/12/25;-Diagnoses included diabetes (a chronic condition in which the body cannot regulate blood sugar levels properly), chronic pain, high blood pressure, and chronic osteomyelitis (an autoimmune disease that causes bone inflammation). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/18/25, showed the following information:-Resident was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-17 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rails; and failed to complete ongoing assessments to ensure the side rails are appropriate for use for eight residents (Resident #1, Resident #2, Resident #12, Resident #19, Resident #47, Resident #86, Resident #77, and Resident #100). The facility census was 93.Review of the facility's policy titled Bed Rails, dated December 2024, showed the following:-Prior to the installation of bed rails, attempts to provide the residents with alternative measures to meet their need for positions, mobility, or transfer ability while in bed will be made;-When alternatives are deemed ineffective or not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection prevention and control program when the facility failed to ensure staff were educated on enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities); failed to ensure staff wore appropriate protective personal equipment (PPE) when providing catheter care for two residents (Resident #1 and #66) with a catheter (flexible tubing that is used to drain urine from the bladder) and when accessing a peripherally inserted venous catheter (PICC - a tube inserted into a large vein near the heart got long term IV access) for one resident (Resident #101); when the facility failed to ensure EBP was care planned for two residents (Resident #1 and #66) with a catheter and one resident (Resident #101) with a PICC; and when the facility failed to post clear signage…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0582 — isolated
    Give 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 Advance Beneficiary Notice (SNFABN - form CMS-10055) or the Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) at the initiation, reduction, or termination of Medicare Part A benefits for two sampled residents (Resident #16 and Resident #107) who remained in the facility upon discharge from Medicare Part A services. The facility census was 93.Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information:-The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons;-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to carry out and document a physician order timely for a discontinued medication and failed to implement monitoring of fluid intake for one resident (Resident #77). The facility census was 93. Review showed the facility did not provide a policy regarding physician orders.1. Review of Resident #77's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 10/08/24;-Diagnoses included diabetes (metabolic disorder characterized by high blood sugar levels), high blood pressure, and congestive heart failure (CHF-chronic condition where the heart doesn't pump blood as well as it should).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 04/18/25, showed the resident was cognitively intact.Review of the resident's care plan, dated 04/28/25, showed the following:-Resident had a self-care deficit and required one staff assistance with activities of daily living (ADL-basic tasks that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff provided respiratory care per standards of practice when staff failed to have a process in place to ensure routine cleaning of a continuous positive airway pressure (CPAP - a mask that uses air pressure to keep the airway open during sleep) device, failed to obtain orders for the use of the CPAP, and failed to include the use of a CPAP on the care plan for one resident (Resident #100). The facility census was 93.1. Review of Resident #100's face showed the following information:-admission date of 08/14/25;-Diagnoses included fracture of the humerus (upper arm bone) on right arm and anemia (deficiency of red blood cells).Review of the resident's discharge instructions from the hospital, dated 08/14/25, showed the resident used a CPAP at bedtime.Observation and interview on 08/26/25, at 2:51 P.M., showed a CPAP sitting on the resident's bedside table. The resident reported he/she was unable to use the CPAP without assistance due to a broken arm, but staff were putting it on him/her.During an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to support each resident's right to self-administer medication when the facility did not explore one resident's (Resident #1) ability to self-administer medications and creams the resident had in his/her room. The facility's census was 71. Review of the facility's policy titled, Medication Storage in the Facility, dated April 2017, showed the following: -Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate per facility policy; -A written order for the bedside storage of medications to be present in the resident's medical record; -Bedside storage of medications is indicated on the resident mediation administration record (MAR) and in the care plan for the appropriate medications; -For residents who self-administer medications, the following conditions are met for bedside storage to occur: the manner of storage prevents access by other residents. lockable…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-16 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility staff failed ensure each resident's right to self-determination was supported when facility staff failed to offer and provide showers as preferred for one resident (Resident #1). The facility census was 71. Review of the facility's policy titled, Activities of Daily Living (ADLs), undated, showed the following: -This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating and communication. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/20/23; -Diagnoses included chronic obstructive pulmonary disease (COPD - a common…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed provide care per standards of practice to all residents when staff failed to to assess, identify, and provide appropriate treatment for a skin condition and failed to notify the physician of the change in condition for one resident (Resident #1) who developed a skin condition on the resident's face and head that required prescription shampoo and cream to treat. The facility census was 71 residents. Review of the facility's policy titled Wound Prevention, revised 8/2023, showed the following: -Conduct a comprehensive assessment upon move in to identify any existing wounds, skin conditions, or risk factors for wound development; -Perform routine skin assessments on all residents during regular monthly assessments; -Document and review the assessed information to establish appropriate wound prevention measures for each resident; -Promote good hygiene practices, including regular showering, and regular changing of soiled garments or incontinence products; -Ensure the use of mild, pH-balanced, fragrance-free soaps,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-01-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain an infection and control program, per standards of practice and facility policy, when the facility failed to ensure two employees (Housekeeper A and Licensed Practical Nurse (LPN) B), of six sampled residents, received tuberculosis (TB-a communicable disease that affects the lungs) screening tests as needed. The facility census was 75. General requirements for Tuberculosis Testing in Long-Term Care Facilities per 19 CSR 20-20.100: -Long-term care facilities shall screen staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -All skin test results are to be documented in millimeters (mm) of induration; -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a two-step TB test (skin test) within one month prior to starting employment; -If the initial test is negative, a second test is required within three weeks after employment begins, unless documentation 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed free from possible contamination and in sound condition in accordance with professional standards when staff failed to dispose of food after expiration, ready-to-eat foods were touched with bare hands, a thermometer was not properly cleaned, and frozen meat was not stored properly. The failed practice had the potential to affect 76 census residents consuming food in the kitchen. Review of the facility's procedure titled, Basics for Handling Food Safety, undated, showed the following: -Do not buy food past sell by, use-by, or other expiration dates; -Don't cross contaminate; -Keep raw meat, poultry, fish, and their juices away from other food; -Make sure thawing meat and poultry juices do not drip onto other food. Review of the facility's policy titled, Dietary Personnel Guidelines, dated 05/2015, showed the following: -Hands and nails should be clean with no colored polish. Review of the facility's policy titled, Glove Use, dated 05/2015, showed the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-11 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to ensure food was palatable, attractive, and at a safe and appetizing temperature in accordance with professional standards for eight residents (Resident #18, #20, #25, #51, #8, #12, #7, and #73) of 20 sampled residents. Review of the facility's policy titled, Food Temperatures, dated 05/2015, revealed Hot food should be at least 120 degrees F [Fahrenheit] when served to the resident. 1. Review of Resident #18's Face Sheet, undated, in the electronic medical record (EMR) showed the following: -admission date of 02/19/20; -readmission date of 03/21/23; -Diagnoses included vitamin deficiency. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 11/30/23, showed the resident was moderately cognitively impaired. During an interview on 01/08/24, at 11:09 A.M., the resident said the food was sometimes cold. The resident said the previous night had grilled cheese and it was cold, greasy, and nasty. He/She…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-11 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure pureed food was prepared properly with appropriate texture in accordance with professional standards for seven residents receiving pureed texture. Review of the facility's procedure titled, Pureed, undated showed pureed food should have a smooth texture with no lumps. During an interview on 01/10/24, at 9:37 A.M., the Dietary [NAME] (DC) said they had seven residents who received the pureed texture. Review of the recipe for the pureed brown sugar glazed ham showed the following: -Prepare according to regular recipe with food thickener and water or stock and process until smooth. During an observation on 01/10/24, at 11:56 A.M., the DC prepared pureed ham. He/she placed plain boiled diced ham into the Robot Coupe (mechanical blender) and turned the machine on for processing. He/she added some liquid to the mixture which contained small undissolved pieces of beef broth. She placed the finished product directly onto the steam table. The pureed ham had the appearance of a mechanical texture. The DC did…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a PASSAR (Preadmission Screening and Resident Review) level one was retained in the resident's medical record and accessible for one resident (Resident #14) of six residents reviewed for PASSAR. 1. During an interview on 01/10/24, at 10:46 A.M., the Administrator said they did not have any specific policy related to PASSAR. Review of Resident #14's Face Sheet, undated, located in the electronic medical record (EMR) under the profile tab, showed the following: -admission date of 09/28/12; -readmission date of 12/26/16; -Diagnoses included anxiety disorder, major depressive disorder, and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 11/18/23, showed the resident had moderately impaired cognition.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure one resident (Resident # 41), of three residents reviewed for activities of daily living/restorative services, received services to maintain or improve walking ability when staff failed to offer to walk with the resident. This failure created a potential for further decline of the resident's lower body strength and walking ability. 1. Review of Resident #41's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 03/20/22; -Diagnoses included dementia, anxiety, unspecified abnormalities of gait and mobility, cognitive communication deficit, generalized muscle weakness, cellulitis (skin infection) of right lower limb, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), cerebrovascular disease, spinal stenosis (a narrowing of the spinal canal in the lower part of the back), weakness, and reduced mobility. Review of the resident's quarterly 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 interviews and record review, the facility failed to ensure two residents (Resident #41 and #65), of five residents reviewed for immunizations, received the pneumococcal vaccination series or had documented refusals. These failures had the potential to increase the spread of pneumonia among the unvaccinated residents. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 01/24/22 and accessed on 01/11/24 at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html showed the following: -For adults 65 years or older, who have not previously received any pneumococcal vaccine, the CDC recommends to give 1 dose of PCV [pneumococcal conjugate vaccine] 15 or PCV20; -If PCV15 is used, this should be followed by a dose of PPSV [pneumococcal polysccahride vaccine] 23 at least one year later; -If PCV20 is used, a dose of PPSV23 is not indicated; -For adults 65 years or older who have only received PPSV23, CDC recommends 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-02 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on interview and record review, the facility failed to report an allegation of possible abuse immediately to facility management and to the State Survey Agency (DHSS - Department of Health and Senior Services) within two hours when two staff failed to report one resident's (Resident #1) allegation of employee to resident physical abuse. The facility census was 81. Review of the facility's policy titled New Abuse/Neglect Report Regulations, dated 11/28/16, showed the following: -Immediately educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The Administrator or designee must report to the State Survey Agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; -Please ensure that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-07-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean manner when staff failed to keep the handsink clean, failed to keep walls in the dishwashing area clean, failed to keep shelves in the walk-in cooler clean, failed to keep an air vent clean, and failed to keep flies to a minimum. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; -Post the schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed; -The purpose to develop detailed cleaning schedules is to ensure sanitation is at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-07-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice when multiple staff did not properly wear face coverings while assisting/conversing with seven residents (Resident #2, #3, #9, #16, #28, #48 and #70) during a coronavirus disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) pandemic. The facility census was 83. Review of the updated guidance for healthcare workers from Centers for Disease Control and Prevention (CDC) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/23/21, showed the following: -Health Care Providers (HCP) should wear well-fitting source control at all times while they are in the healthcare facility; -Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-07-26 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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, interview, and record review, the facility failed to ensure the floors throughout the kitchen were kept clean and free from debris. The facility census was 83. Record review of Cleaning Schedules, dated April 2011, showed the following: -It is the responsibility of the Dining Services Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the Dining Services Manager with all cleaning tasks listed will be posed in the Dietary Department; -It will specify the days the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and positions; -Post the schedule prior to the beginning of each week and the employee will initial in the column under the day the task is completed; -The purpose to develop detailed cleaning schedules is to ensure sanitation is at acceptable standards. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Non food-contact surfaces shall be kept free of an accumulation of…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-07-26 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 an effective pest control program to control the fly population in resident rooms on the 300 hall including rooms of six residents (Resident #11, #20, #40, #55, #56, and #57). The facility census was 83. Record review of the facility's policy Pest Control, undated, showed the following: -Purpose to provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Record review of the facility's completed maintenance work orders for April 2021 to July 23, 2021, showed no mention of flies in the facility. Record review of the pest control company's proof of service, dated 6/11/21, showed: -Inspected throughout all areas of the facility and found no pest concerns; -Sites inspected included kitchen, dining room, and exterior of building with…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 observation, interview, and record review, the facility staff failed to report an allegation of abuse to the state survey agency (Department of Health and Senior Services - DHSS) when one resident (Resident #71) stated that Nurse Aide (NA H) and one resident (Resident #49) were having an affair. The facility census was 83. Record review of the facility's Abuse Prevention Policy, dated 11/28/16, showed the following information: -Immediately educate all staff to report to the administrator and/or designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The administrator or designee must report to the state survey agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 the cleanliness of resident oxygen nasal cannula tubing and failed to ensure the oxygen humidification bottle contained water for one resident (Resident #1). The facility census was 83. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; -Oxygen therapy is usually combined with a humidification device, to prevent mucosal dryness; -Because oxygen concentrator tanks deliver absolutely dry oxygen, humidification is recommended by some; -If humidification is used, the most widespread system is the bubble through humidifier. Record review of the facility policy titled, Cleaning Guidelines Oxygen Equipment, (undated), showed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-26 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physicians' orders for bed rails and failed to complete bed rail assessments and measurements to check for risk of entrapment for two residents (Resident #180 and Resident #181). The facility census was 83. Record review of the facility's policy titled, Physical Restraints, undated, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body; -Determine the type of side rails to be used; -Determine the medical symptoms to be treated with side rails; -Involve the resident and the resident's representative in planning for side rail use. Many residents request to have side rails up when in bed to improve bed mobility and provide a feeling of safety 1. Record review of Resident #180's face sheet (a document that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to JAMES & JUDY LINCOLN — 56 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 →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 3 of 52.4+0.6 vs chain
The other 55 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Camdenton Windsor EstatesCamdenton, MO 1 of 5Crestview HomeBethany, MO 1 of 5Grand River Health CareChillicothe, MO 1 of 5Joplin GardensJoplin, MO 1 of 5Lebanon North Nursing & RehabLebanon, MO 1 of 5Lewis & Clark GardensSaint Charles, MO 1 of 5Maryville Rehabilitation & Health Care CenterMaryville, MO 1 of 5Pacific Care CenterPacific, MO 1 of 5Parkside ManorColumbia, MO 1 of 5Pin Oaks Living CenterMexico, MO 1 of 5River City Living CommunityJefferson City, MO 1 of 5Rocky Ridge ManorMansfield, MO 1 of 5South Hampton Rehabilitation & Health Care CenterColumbia, MO 1 of 5Springfield VillaSpringfield, MO 1 of 5Strafford Rehabilitation & Health Care CenterStrafford, MO 1 of 5Troy ManorTroy, MO 1 of 5Villa At Blue Ridge, TheColumbia, MO 1 of 5Warrenton ManorWright City, MO 1 of 5Woodland Hills Healthcare And RehabilitationJacksonville, AR 2 of 5Brookhaven Nursing & RehabSpringfield, MO 2 of 5Carroll HouseCarrollton, MO 2 of 5Current River Rehabilitation & Health Care CenterDoniphan, MO 2 of 5Eldon Nursing & RehabEldon, MO 2 of 5Fulton Nursing & RehabFulton, MO 2 of 5Grandview Healthcare CenterWashington, MO 2 of 5Lebanon South Nursing & RehabLebanon, MO 2 of 5Point Lookout Nursing & RehabHollister, MO 2 of 5Shepherd Of The Hills Living CenterBranson, MO 2 of 5Sunset HomeMaysville, MO 2 of 5Willard Care CenterWillard, MO 2 of 5Windsor Rehabilitation & Health Care CenterWindsor, MO 3 of 5Claru Deville Nursing CenterFredericktown, MO 3 of 5Glasgow GardensGlasgow, MO 3 of 5Glendale Gardens Nursing & RehabSpringfield, MO 3 of 5Hartville Care CenterHartville, MO 3 of 5Hermitage Nursing & RehabHermitage, MO 3 of 5Maries ManorVienna, MO 3 of 5St James Living CenterSaint James, MO 4 of 5Clearview Nursing CenterSikeston, MO 4 of 5Crowley Ridge Care CenterDexter, MO

Showing 40 of 55; lowest-rated first.

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 / managerTypeRoleShareSince
LINCOLN, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 10/01/1995
LINCOLN, JUDYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 10/01/1995
OSENGA, JEREMYIndividualW-2 MANAGING EMPLOYEEsince 09/21/2017
DRAKE, TIMOTHYIndividualCORPORATE DIRECTORsince 04/30/2013
STUTTS, CHARLOTTEIndividualCORPORATE OFFICERsince 04/30/2013
FORSYTH MANOR INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/1995

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.

$6.1M
Net patient revenuemost recent cost report
-7.5%
Operating marginrevenue minus expenses
$2.2M
Related-party expense33% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 4%Other / private 42%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 33% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$218per resident / day
operating cost
$6,634per month
≈ monthly operating cost
$203per day
avg. revenue, all payers

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

What families pay in MO

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265605. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next