Kingdom Care Senior Living
811 Center Street, Fulton, MO 65251 · For profit - Limited Liability company · 36 certified beds · (573) 642-6646 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 5 to 4 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 | 20.0% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.4% | 5.3% | 5.4% | better |
| 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 | 2.4% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 18.5% | 6.5% | check this* — see note marked star 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 | 3.5% | 4.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.2% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 52.2% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.2% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.7% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.1% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 17.6% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 37.4% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.4% | 13.7% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.6% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.7% 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 21 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 45.6%CMS range 31.4–59.6 | 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 | 11.1%CMS range 7.6–17.3 | 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 | 85.7% | 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 | 90.5% | 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 | 66.7% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 36 beds and averages 27.4 residents a day — about 76% occupied, or roughly 9 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.06 on weekdays — 14% thinner on weekends. RN hours go from 0.60 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · F2026-04-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility staff failed to store and serve food at temperatures adequate to prevent food-borne illness and in a manner to prevent contamination and outdated use. Facility staff also failed to allow mechanically washed dishes to air-dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 27.1. Review of the facility's policy titled Record of Food Temperatures, undated, showed it is the policy of the facility to record food temperatures to ensure food is at the proper serving temperatures. Review showed potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit (dF). Review showed the policy directed staff to measure and record temperatures for each food product and milk at all meals. Observation on 04/13/26 at 10:51 A.M., showed an unidentified Dietary Aide (DA) prepared the salad bar for the lunch meal. Observation showed the DA placed multiple food items in bowls which were placed 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 · Fcited before2026-04-15 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, facility staff failed to document a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility and consider specific staffing needs for each shift, such as day, evening, night or include active involvement in the process from direct care staff, including but not limited to: Registered Nurses (RN), Licensed Practical Nurses (LPN), Nurse Aides (NA), and representatives of the direct care staff, if applicable, and/or solicit and consider input received from residents, resident representatives, and family members. The facility census was 27.1. Review of the facility's Facility Assessment policy, dated October 2018, showed the residents, representatives and family members may be asked to participate in the review of the care and services provided to meet the needs of our residents. The policy did not contain documentation or assessment of staffing needs of each unit or shift. Review of the Facility Assessment, dated 04/01/26, showed the workforce profile includes the following direct care staff type 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.
- Potential for harm · E2026-04-15 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #1, # 9, #17, and #23) of twelve sampled residents. The facility census was 27.1. Review of the facility's Comprehensive Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment;-The comprehensive, person-centered care plan:-Includes measurable objectives and timeframes;-Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being;-Includes resident stated goals and outcomes;-Builds on resident strengths;-Reflects current recognized standards of practice for problem areas and conditions. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/15/26, showed staff assessed the resident as cognitively intact. Review 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.
- Potential for harm · Ecited before2026-04-15 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for five residents (Resident #2, #8, #13, #19, and #23) out of twelve sampled resident care plans. The facility census was 27.1. Review of the facility's Comprehensive, Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being; -Includes resident stated goals and outcomes; -Builds on resident strengths; -Reflects current recognized standards of practice for problem areas and conditions. -Assessments are on-going and care plans are revised as information about the resident condition changes; -The Interdisciplinary team (IDT) revise and updates the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility staff failed to provide an environment free from accident hazards, when staff failed to lock medication carts when unattended and not in use and store chemicals when not in use. The facility census was 27.1. Review of the facility's Medication Storage policy, dated 2026, showed: -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls;-Only authorized personnel will have access to the keys to locked compartments;-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 2.Observation on 04/12/26 at 9:15 A.M., showed one unlocked and unattended treatment cart and one unlocked unattended medication cart at the nurse's station. Observation showed residents and staff walked by carts. Observation on 04/12/26 at 7:38 A.M., showed an unlocked treatment cart at the nurse station. Registered Nurse (RN) C had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-15 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, facility staff failed to educate and offer Coronavirus disease 2019 (COVID-19), a respiratory disease that can cause severe illness, immunizations to residents as required for four residents (Residents #8, #13, #15, and #25) of five sampled residents. The facility census was 27.1. Review of the facility's policy COVID-19 Vaccination dated 2025, showed the facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of each. A copy of the Vaccine Information Statement will be given to staff, residents and resident representatives prior to administration. Review of Resident #8's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season. Review of Resident #13's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season.Review of Resident #15's medical record showed the record did not…
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 · D2026-04-15 · 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, facility staff failed to perform a significant change in status (SCSA) Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for two (Resident #8 and #23) of three residents who elected hospice services and one (Resident #19) of four sampled residents who had a change in activities of daily living. The facility census was 27.1. Review of the facility's MDS 3.0 Completion policy, dated 2025, showed:-The facility conducts periodic comprehensive, accurate, and standardized assessment of each resident's functional capacity using the Resident Assessment Instrument (RAI) manual specified by the state;-A SCSA is a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter Two of the RAI manual;-A SCSA is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical…
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 · D2026-04-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to obtain orders for an indwelling urinary catheter and catheter care for one resident (Resident #2) out of one sampled resident, failed to obtain an order for hospice for one (Resident #23) out of three sampled residents, and failed to notify the physician when one (Resident #17) of four sampled residents did not receive his/her medication as ordered. The facility census was 27.1. Review of the facility's Indwelling Catheter Care policy, undated, showed ff an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to insertion, ongoing care and catheter removal protocols that adhere to professional standards of professional and infection prevention and control procedures. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool,…
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 · D2026-04-15 · tag F0840 — isolatedEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, facility staff failed to ensure arrangements were made for nephrology (services that provide care for kidney related conditions) services outside of the facility for one resident (Resident #35) of one sampled resident with kidney disease. The facility census was 27.1. Review of the facility's admission Agreement, undated, showed if a resident chose a physician who does not have privileges at the facility, the resident must travel, at their own expense, to the healthcare provider to receive services from that provider. The agreement did not contain direction or guidance on assistance to set up transportation for ordered services or assistance in set up for the appointments. Review of Resident #35's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/01/26, showed staff assessed the resident as: -Cognitively intact;-Always incontinent of bladder;-Diagnosis of impaired kidney function. Review of the resident's nurse's notes, dated 01/01/26 through 03/31/26, showed staff documented: -02/08/26: Order received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-06 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for facility residents competently during both day-to-day operations and emergencies as required. The facility census was 26. 1. Review of the facility's Facility Assessment Report, dated July 2024, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required. During an interview on 1/6/25 at 10:02 A.M., Licensed practical Nuse (LPN) A said he/she is responsible for the nursing staff schedule. He/She said he/she schedules a consistent schedule based on the census and not according to resident acuity. He/She said he/she does not know what the facility assessment directs for staffing. During an interview on 1/6/25 at 11:01 A.M., the corporate director of finance said the previous administrator left abruptly and he/she at the facility to help until a new administrator is hired. He/She said the July 2024 is the only facility assessment the facility has and 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.
Show the remaining 17 citations
- Potential for harm · E2025-12-17 · tag F0567 — failed to protect residents' money held by the home — patternHonor 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 interview and record review, facility staff failed to prevent the commingling of nine residents (Resident #6, #7, #8, #9, #10, #11, #12, #13, and #14) personal funds with the facility operating funds out of 13 sampled residents. The facility census was 28.1.Review of the facility's admission assessment, revised 09/12/25, showed:-The facility must establish and maintain a system that assures a full and complete separate accounting, according to generally accepted accounting principles;-The system must preclude any commingling of resident funds with facility funds or with funds any other person other than the resident;-The individual financial record must be available to the resident through quarterly statements and upon request;-The facility must refund the resident or the resident representative any and all funds due to the resident within 30 days from the date of the resident's discharge. 2.Review of the facility-maintained Accounts Receivable (AR) Aging report, dated 12/17/25, showed the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a clean, safe, and comfortable home-like environment when staff failed to adequately maintain doors and keep walls in resident rooms free of gouges in the drywall and scrapes in the paint. The facility census was 26. 1. Review of the facility's policy titled Quality of Life-Homelike Environment, dated May 2017, showed residents are provided with safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, to include clean, sanitary and orderly environment. 2. Review of the facility's policy titled Maintenance Service, dated December 2009, showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include maintaining the building in compliance with current federal,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #9 and #28) of a sample of two residents. The facility census was 26. 1. Review of the facility's titled Enhanced Barrier Precautions, undated, showed EBP are an infection control intervention designed to reduce the transmission of Multidrug-Resistant Organisms (MDROs) in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high-contact resident care activities. High-contact resident care activities are activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Example of high-contact care activities include, but are not limited to dressing, bathing, transferring, providing hygiene,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-12 · 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 observation, interview, and record review, facility staff failed to update the care plans for meal assistance for two residents (Resident #3 and #24) and for bed rail usage for one resident (Resident #3) of 19 sampled residents. The facility census was 26. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centers dated, December 2016 says; -The interdisciplinary team should develop and implement a comprehensive, person-centered care plan for each resident, -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, -Care plans will include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 2. Review of Resident #3's care plan dated, 10/14/23, showed staff documented 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 · D2024-09-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to obtain a physician's order for and failed to update the plan of care for one resident (Resident #23) out of two sampled residents who received oxygen therapy. The facility census was 26. 1. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed staff are directed to verify there is a physician's order. Review the physician's order or facility protocol for oxygen administration. Review the care plan to assess for any special needs of the resident. 2. Review of Resident #23's admission Minimum Data set (MDS), a federally mandated assessment tool, dated 07/07/24, showed staff assessed the resident used oxygen. Review of the resident's Physician Orders Sheet (POS), dated September 2024, showed it did not contain an order for oxygen. Review of the resident's care plan, dated 07/07/24, showed staff documented the resident used oxygen continuously. Review showed staff documented the resident is unable to propel self and manage the oxygen concentrator. 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 · E2023-09-13 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) as directed in their policy. The facility census was 29. 1. Review of the facility's policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed staff were directed to conduct employee background checks and not knowingly employ or otherwise engage any individual who has a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident or misappropriation of resident property. 2. Review of Housekeeper A's employee file showed: -Hire date of 08/10/23; -The file did not contain documentation 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.
- Potential for harm · Ecited before2023-09-13 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff, failed to update and revise care plans with the interdisciplinary team (IDT) for three residents (Resident #1, #2, and #8). The facility census was 29. 1. Review of the facility's policies showed staff did not provide a policy for care plan meetings. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited one person assistance for bed mobility, transfers, toileting, and personal hygiene; -Diagnosis of Depression (a depressed mood or loss if pleasure or interest in activities for long periods of time). Review of the resident's care plan signature sheet, dated 06/16/23, showed the sheet did not consist of an IDT team. Review of the resident's medical record showed the record did not contain documentation of the IDT team was invited or attended a care plan meeting. 3. Review of Resident #2's Quarterly MDS, dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to ensure safe propulsion for three residents (Resident #4, #8, #12, and #15) in wheelchairs in a manner to prevent accidents. The facility census was 29. 1. Review of the facility's Manual Wheelchair safety and Maintenance policy, undated, showed the following: -No pedals-No push; -Always propel a resident in a forward position; -Always ensure leg rests and foot pedals are in the correct position and in use when propelling a resident in a wheelchair. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/03/23, showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of Renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease.), Dementia (loss of cognitive functioning thinking, remembering, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-13 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, side rails assessments, obtain informed consent and a physician order for the use of side rails and/or grab bars for four residents (Residents #4, #9, #18, and #25). The facility census was 29. 1. Review of the facility's Bed Safety, revised December 2007, directed staff as follows: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -Review of the gaps within the bed system are within the dimensions established by the FDA (Note: the review shall consider situations that could be caused by the resident's weight, movement or bed position); -The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 2. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment tool, 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 · Ecited before2023-09-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for two residents (Resident #8 and #12), when staff failed to change oxygen tubing for three residents (Resident # 1, #17 and #178), and prevent one resident's (Resident #11) catheter tubing from laying on the ground. Additionally the facility failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed and on file in accordance with their policy for four employees (Certified nursing assistant (CNA) E, F and G, and housekeeper A). The facility census was 29. 1. Review of the facility's Handwashing/Hand Hygiene policy, undated, showed staff were directed to the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread 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.
- Potential for harm · D2023-09-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for one resident (Resident #1). The facility census was 29. 1. Review of the facility's Do Not Resuscitate Order Policy, revised [DATE], showed staff are directed as follows: -Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record; -The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine the resident wishes to make changes in such directives. Review of the facility's Advance Directives Policy, revised [DATE], showed information about whether or not the resident had executed an advance directive shall be displayed prominently in the medical record. 2. Review of Resident #1's Physician Order Sheet (POS), showed an active order…
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 · D2023-09-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility staff failed to implement dietician recommendations after an acute illness and change in appetite to prevent weight loss for one of one sampled resident (Resident #21). The facility census was 29. 1. Review of the facility's Nutritional Assessment Policy revised October 2017, showed as part of the comprehensive assessment, a nutritional assessment including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietician, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering an interpreting data and using that data to help define meaningful interventions for the resident at risk for or 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.
- Potential for harm · D2023-09-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to ensure one (Resident #20) of one sampled residents received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to obtain orders for dialysis and provide ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 29. 1. Review of the policies provided by the facility showed no direction for staff in regard to dialysis care for residents. 2. Review of Resident #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/21/23, showed facility staff assessed the resident as: -Moderate cognitive impairment; -Received dialysis; -Diagnoses of End Stage Renal Disease (ESRD) a longstanding disease of the kidneys leading to renal failure. Review of the resident's care plan, dated 09/07/23, showed no direction for staff in regard to the resident's dialysis…
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 · Ccited before2026-04-15 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 to provide a clean, comfortable and homelike environment for residents, when staff failed to maintain one of one shower rooms free of an excessive buildup of foreign material. This failure has the potential to affect all residents. The facility census was 27.F1. Review of the facility's policy titled Safe and Homelike Environment, dated 2025, showed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Review showed the policy did not contain specific guidance related to the resident shower room. Observation on 04/14/26 during the Life Safety Code tour showed the facility equipped with one shower room for use by all residents. Observation showed the spa tub contained a large amount of brown discoloration that extended from the faucet all the way down the tub to the drain area. Observation showed all three walls of the shower, the shower grab bar, and the shower caddy contained a large amount of a thick white substance. Observation…
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 · C2024-09-12 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 26. 1. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated August 2022, showed staff were directed to do the following: -Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; -Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses (RN), Licensed Practical Nurses (LPN) and the number of unlicensed nursing personnel (Certified Nurse Aides (CNA) and Nurse Aides (NA) directly responsible for resident care is posted in a prominent location accessible to resident and visitors and in a clear and readable format; -The information on the form shall include 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 · C2023-09-13 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview and record review, the facility staff failed to post, in a form and manner accessible to the residents and resident representatives, the Department of Health and Senior Services (DHSS) Elder Abuse hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA). The facility census was 29. 1. Review of the facility's Resident's Rights Policy, revised 03/01/2023, showed: -The facility must post, in a form and manner accessible and understandable to residents, and resident representatives: -A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the state survey agency, the state licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities; -A statement that the resident may file a complaint with the state survey agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to 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.
- No harm found · C2023-09-13 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #9, #14, and #179) out of three sampled residents. The facility's census was 29. 1. Review of the facility's policies showed staff did not provide a policy for bed holds. 2. Review of Resident #9's medical record showed the following: -Cognitively intact; -discharged from the facility on 06/18/23 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #14's medical record showed the following: -Cognitively intact; -discharged from the facility on 07/04/23 and readmitted to the facility on [DATE]. -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 4.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AYCOCK, MICHELLE | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/12/2020 |
| AYCOCK, WILLIAM | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/15/2020 |
| GERARD, CHANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2021 |
| YOUNG, BOBBIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/15/2020 |
| SJOBLOM, BETH | Individual | ADP OF THE SNF | since 01/01/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 5 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.
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.
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
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 265581. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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