Gainesville Nursing
77 Medical Drive, Gainesville, MO 65655 · For profit - Corporation · 99 certified beds · (417) 679-4921 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (2/5)
- its facility-reported quality-measure rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.8% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.9% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 10.5% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 22.9% | 18.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.6% | 0.0% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.4% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.9% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 87.2% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.0% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.7% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 43.5% | 63.5% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.85 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.24 | 2.33 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.6% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.6%CMS range 38.9–65.9 | 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 | 11.3%CMS range 7.0–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 4.8% | 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 | 6.8%CMS range 3.7–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 46.9 residents a day — about 47% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.63 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.32 hrs/resident/day on weekends vs 2.76 on weekdays — 16% thinner on weekends. RN hours go from 0.67 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
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 · Ecited before2026-03-12 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for 19 missing narcotics tablets for 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). The facility census was 43. Review of the facility policy titled Abuse, Prevention and Prohibition Policy, revised 10/22, showed the following information:-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility.Review of the facility policy titled, Medication Administration-General Guidelines, dated 01/01/18, showed the following information:-If a medication with a current, 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 · Dcited before2026-01-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect all resident from misappropriation of property when one facility staff member (Environmental Services Employee A) used one resident's (Resident #1) debit card without consent. The facility census was 46.On 12/26/25, the Social Services Worker became aware of the misappropriation. The facility immediately began their investigation, including multiple interviews of other residents and staff. The facility began education on abuse, neglect, and misappropriation of resident's property. The facility removed Environmental Services Employee A from the facility. The facility reviewed all other resident's accounts with a debit card, as well as educated the residents on the process for debit card transactions. The facility reported the misappropriation to the Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 12/27/25. Review of the facility policy titled, Abuse, Prevention and Prohibition Policy, revised 10/22, showed, the following:-The facility prohibits…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Please refer to Event ID B3N912, exit date 11/14/24. Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Please refer to Event ID B3N912, exit date 11/14/24. Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Investigation. -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 before2024-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 observation and interview, the facility failed to ensure food prepared by the facility was palatable when residents complained the food was served cold at times, the food lacked flavor/seasoning, and the meat was tough at times. 1. Observations and interview on 09/11/24, at 1:07 P.M., showed the following: -The Dietary Manager (DM) confirmed testing the food on the last (test) tray on the cart. Prior to leaving the kitchen the temperature of the cheesy rice casserole was 120 degrees Fahrenheit (F); pork chop was 125 degrees F; and the broccoli was 115 degrees F. -When the tray was presented after the last tray was delivered, the casserole was 110 degrees F, the pork chop was 95 degrees F, and the broccoli was 90 degrees F. -The DM said the food was cool and should have been warmer to be palatable for the residents. Interviews during the Resident Council Meeting on 09/11/24, at 9:15 A.M., showed the residents said the food was cold for the residents who eat in their rooms. The pancakes that morning were cold. The prior night (09/10/24) the menu said burrito with beans/rice,…
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 F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial notifications of all listed on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Investigation. -The facility Administrator will ensure a thorough…
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 F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop complete a person centered care plan for each resident when staff failed to care plan related to side rails use for one resident (Resident #13) and wandering/elopement risks for one resident (Resident #36) of 21 sampled residents. Review of the facility's Care Planning - Interdisciplinary Team policy, dated January 2017 showed the following: -Upon completion of comprehensive assessments care areas of concern will be triggered to be addressed in the plan of care for that resident. -Each triggered care area will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life. -Staff will document whether or not a care plan is needed to address the triggered area. 1. Review of the facility policy titled Proper Use of Side Rails, reviewed 02/2021, showed the use of side rails will be addressed in the resident's care plan. Review of Resident #13's admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when staff failed to evaluate effective of interventions, care plan new interventions, and failed to complete root cause analysis after multiple elopement attempts and combativeness for one of two residents (Resident #22) reviewed for wandering. Review of the facility's policy titled Elopement Policy, undated, showed it was the intent of the facility to maintain and enhance a resident's dignity by promoting free access in and around the facility, while safeguarding the well-being of the resident, and to monitor behavior or residents to identify potential elopers, such as excessive wandering, especially to doors. 1. Review of Resident #22's admission Record, undated, found under the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 06/15/23; -Diagnoses included dementia. Review of the resident's annual Minimum Data Set (MDS - federally mandated assessment completed by facility staff),…
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 F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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 observation, interview, and record review, the facility failed to ensure all food was prepared in a form designed to meet the needs of each resident when the facility failed to cut up meat as ordered for one resident (Resident #17). Review of the facility policy titled Menus and Food Preparation-Nutrition Services, revised January 2018, showed the purpose of the policy was to ensure resident nutritional needs are met in conjunction with resident preferences. 1. Review of Resident #17'sadmission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 10/18/21; -readmission date of 08/09/22; -Diagnoses included gastroesophageal reflux disease. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/23/24, showed the resident was cognitively intact. Review of the resident's Orders tab in the EMR showed a physician's order, dated 07/18/24, for regular texture, regular…
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 15 citations
- Potential for harm · E2022-11-17 · 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, the facility failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for five residents (Residents #8, #12, #27, #31, and #199); failed to obtain informed consent prior to the use side rails for one resident (Resident #31); failed to address the use bed rails in residents' care plans for four residents (Residents #8, #12, #31, and #199); and failed to obtain physician's orders for bed rail use for two residents (Resident #12 ad #199); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 48. Record review of a facility policy entitled Proper Use of Side Rails, reviewed 2/2021, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails and will be reviewed…
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 · D2022-11-17 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #37) and failed to notify the ombudsman of transfers to the hospital for two residents (Residents #6 and #37). The facility census was 48. Record review showed the facility did not provide a a written policy pertaining to transferring a resident to the hospital. Record review of a facility form entitled Notice of Resident Transfer or Discharge, revised 11/2016, showed the following spaces to fill: -Date of notice; -Name, address, city, state, and zip (did not specify for whom); -Salutation to addressee; -Name of resident; -Name and location of institution where resident to be transferred/discharged ; -Date of transfer; -Rationale for transfer; -Facility contact information for appeal; -Information regarding State Long-Term Care Appeal Agency, State Ombudsman, State Agency for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-17 · tag F0625 — isolatedNotify 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, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #6 and #37) who were transferred out to the hospital. The facility census was 48. Record review of the facility's policy entitled Bed Hold Policy & Agreement Form, revised February 2014, showed the following: -Purpose to establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement To Pay Charges For Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his or her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines; -The Bed Hold Agreement is to be obtained for each occurrence - hospital or therapeutic home leave; -When hospital or therapeutic home leave is reported on the Midnight Census, the Social Service Director (SSD)/Business Office will notify…
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 · D2022-11-17 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #6) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 48. Record review showed the facility did not provide a policy regarding PASARR requirements. 1. Record review of Resident #6's Level 1 Nursing Facility Pre-admission Screening for Mental…
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 · D2022-11-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure proper care for all residents with catheters (a sterile tube inserted into the bladder to drain urine) when staff failed to obtain updated physician orders for an indwelling catheter for one resident (Resident #12). The facility census was 48. 1. Record review of Resident #12's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/26/22, showed the following information: -admitted to the facility on [DATE]; -Diagnoses included history of neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition); -Cognitively intact; -Total dependence on staff assistance for transfers, dressing, toileting, and bathing; -Limited assistance required with bed mobility and personal hygiene; -Always continent of bowel and bladder; -Indwelling catheter present. Record review of the resident's care plan, dated 9/14/22, showed the following: -Resident has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-17 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one nursing assistant (NA B) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. This deficient practice had the potential to affect all residents who received care from the NA. The facility's census was 48. Record review showed the facility did not provide a written policy pertaining to Certified Nurse Aide (CNA) training and certification testing. 1. Record review of NA B's personnel file showed the following: -Date of hire: 6/28/2022; -Staff did not have documentation NA B had completed the nurse aide training program and passed the required certification testing. Record review of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. Observation on 11/14/2022, at 1:02 P.M., showed NA B was passing meal trays wearing a name tag with his/her name and title of NA. During the observation, he/she told the surveyor that he/she had been employed at the facility since June 2022.…
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 · F2019-10-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to follow proper hand hygiene when handling food items and food contact surfaces; when staff failed to properly wear facial hair nets and hair nets; when staff failed to ensure that the warewasher was working properly; and when staff failed to keep open drinks out of the kitchen. The facility had a census of 49 residents. 1. Record review of the 2013 Food and Drug Administration (FDA) Food Code showed the following information: -Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-10-24 · 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, the facility failed to develop a comprehensive care plan that included interventions to address facility identified resident care needs for three residents (Resident #2, #25, and #146) in a sample of 18 residents in a facility with a census of 49. 1. Record review of Resident #25's nurses' notes, dated 8/13/19, showed the resident admitted to the facility. The resident reported blindness in the right eye and vision clear in the left eye. The resident did not wear glasses. Record review of the resident's physician progress notes, dated 8/14/19, showed the resident had head trauma injury several years prior and became combative and verbally abusive. Since that time, his/her organic brain trauma has been complicated by dementia. Record review of the resident's nurses' notes, dated 8/15/19, showed the resident's right pupil larger than the left. The resident said, in case you didn't notice, I'm blind in that eye. Record review of the resident's nurses' notes, 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 · E2019-10-24 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food in a form to meet each resident's nutritional needs when staff did not follow portion sizes for mechanical soft diets or prepare and serve pureed foods according to the approved recipe and the correct consistency for three residents (Resident #9, #11, and #16). The facility census was 49. Record review of facility records showed the facility did not provide a policy for therapeutic diets. 1. Record review of the facility's weekly menu, dated October 20, 2019 through October 26, 2019, showed the following information: -Wednesday, October 23, 2019: Salisbury steak, au gratin potatoes, and mixed vegetables; -Thursday, October 24, 2019: Roast turkey with gravy, sweet potatoes, and whole green beans. Record review of the facility's menu cycle, entitled Week 1 Wednesday, showed the following information: -Mechanical soft diet: one-half cup Salisbury steak; -Pureed diet: one-half cup Salsibury steak with pureed bread, one-half cup…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-10-24 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve residents, including six sampled residents (Resident #4, #15, #17, #26, #33, and #196) palatable and attractive food to resident. The facility census was 49. 1. Record review of the facility's resident council minutes dated 6/18/19, at 10:30 A.M., showed the meat was too tough to cut. Record review of the facility's resident council Quality of Life questionnaire, dated 6/18/19, showed the following information: -Is the flavor and appearance of your food satisfactory? Sometimes; -Are the meats tender enough? No. Record review of the facility's grievance log dated 6/18/19, showed Resident #33 filed a grievance and said the meat was still tough. Record review of the facility's resident council minutes dated 7/16/19, at 10:15 A.M., showed the the food did not taste good. Record review of the facility's resident council minutes dated 8/13/19, at 10:15 A.M., showed the following information: -Food discussed during food forum; -Meat 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.
- Potential for harm · D2019-10-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 treated each resident with respect and dignity when staff failed to interact with one resident (Resident #196) in a respectful manner while assisting the resident to eat. The facility census was 49. 1. Record review of Resident #196's 5 day Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/30/19, showed the following information: -Original admission date of 5/1/19; -Diagnoses included Alzheimer's disease, dementia, diabetes, anxiety disorder, seizure disorder, and psychosis; -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, and eating. Observation on 10/22/19, beginning at 12:55 P.M., showed the following: -The resident sat in the television room alone and reached for a cup of water; -The resident knocked over the cup. The resident continued to try to reach it; -Certified Nursing Assistant (CNA) H entered the television room, shoved the resident's tray out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' end of life wishes reflected throughout the medical record remained consistent for two residents (Resident #4 and #246) out of a sample of 18 residents. The facility census was 49. Record review of the American Heart Association website, showed the following information regarding Advance Directives: -Advance directives, also referred to as living wills, can address a number of issues, such as whether a patient wants to receive artificial respiration, dialysis, tube feeding or artificial hydration, or donate an organ in the event of death. The document may also include a do-not-resuscitate-order, which instructs doctors not to perform cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) if the patient stops breathing or their heart stops. -An advance directive provides a clear statement by the patient of his or her wishes with respect to his or her health care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to check one resident's (Resident #1) blood glucose level (blood test to determine glucose level) before meals as ordered by the physician and according to the standard of practice. Facility staff failed to administer two residents' (Resident #1 and #146) insulin injections timely and as ordered by the physician. Staff failed to ensure the resident's physician orders included the sliding scale for insulin administration ordered by the physician. A sample of 18 residents was reviewed in a facility with a census of 49. Record review of a facility policy and procedure entitled, Insulin Administration (Revised April 2007), showed the following information: -The three key characteristics of insulin are onset of action (how quickly the insulin reaches the bloodstream and begins to lower blood glucose); peak effects (the time when the insulin is at its maximum effectiveness); and duration of effects (the length of time during which the insulin is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care plan and implement effective interventions to prevent one residents (Resident #25) from exiting the facility and/or wandering into another resident's room. The facility census was 49. 1. Record review of Resident #25's face sheet (brief resident information sheet), showed the following information: -admitted to the facility on [DATE]; -Diagnoses included unspecified dementia with behavioral disturbance. Record review of the resident's physician order sheet (POS) showed order, dated 8/13/19, for Perphenazine, 4 milligram (antipsychotic medication) three times a day. Record review of the resident's nurses' notes, dated 8/13/19, showed the resident as alert and oriented to self, forgetful. The resident had poor short term memory. Staff to monitor safety awareness. The resident forgot to lock his/her wheelchair before standing. Record review of the resident's social services progress note, dated 8/13/19, showed the resident admitted from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-24 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 attempt effective interventions, including non-pharmacological interventions and failed to develop an individualized, person-centered care plan to meet the needs of one resident (Resident #32) with dementia and exhibiting continued behaviors. The facility census was 49. Record review of the facility's (undated) behavior policy showed the following information: -Goal was to encourage individual resident independence and autonomy by structuring a least restrictive environment which allows each resident to be restraint free for optimal periods of time and enhances the goal of quality therapeutic, preventative, restorative, and rehabilitative care; -Objective was to provide health care services which allow the resident to attain the highest practicable physical, mental and psychosocial well-being using the least restrictive method practicable for the shortest period of time necessary; -Appropriate support services are available to implement…
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.
Part of a chain
This home belongs to COMMUNITY CARE CENTERS — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 1 of 5 | 2.0 | -1.0 vs chain |
The other 7 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WEINER, CRAIG | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/06/2025 |
| WEINER, GINA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 01/06/2025 |
| GC ASSET MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/2025 |
| BEASLEY, SHERRI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/24/2026 |
| HENEGAR, EDWARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/24/2026 |
CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $315K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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
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 265312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-12, 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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