Monterey Park Rehabilitation & Health Care Center
4600 Little Blue Parkway, Independence, MO 64057 · For profit - Corporation · 122 certified beds · (816) 795-7888 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 3 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 | 4.7% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.0% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.5% | 18.5% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.5% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.5% | 17.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 25.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.5% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.5% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.1% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 37.2% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 2.1% | 13.7% | 12.0% | better |
‡ 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.
50.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 50.9%CMS range 41.7–58.7 | 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 | 11.9%CMS range 8.7–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.4% | 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 | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 32.1% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.7% | 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 | 7.5%CMS range 4.7–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 122 beds and averages 91.8 residents a day — about 75% occupied, or roughly 30 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.24 hrs/resident/day on weekends vs 3.90 on weekdays — 17% thinner on weekends. RN hours go from 0.33 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% 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 fewer than at the previous inspection — improving. 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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Fcited before2025-11-18 · 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 staff member working in the kitchen failed to wash their hands, providing a risk of cross contamination between objects and food. This practice potentially affected all residents who ate the food from the kitchen. The facility census was 98 residents.Review of the facility's undated Handwashing Policy and Procedure showed:-Hand washing was the most important component for preventing the spread of infection. Proper hand washing technique was to be used at all times that hand washing is indicated.-Hand washing was to be done:--When hands were visibly soiled.--Before and after eating or handling food.--After toileting or after personal grooming (combing hair).--Before starting work.--After smoking.--After coughing, sneezing, or blowing your nose.--After handling uncooked animal products such as raw meat, or fish.1. Observation on 9/25/25 from 9:30 A.M. to 12:00 P.M. during the lunch meal preparation showed:-Dietary [NAME] A grabbed the ready to eat pies in a way that his/her ungloved hand full length of his/her thumbs were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 interview and record review, the facility failed to notify a resident's emergency contact in a timely manner for one sampled resident (Resident #54) when on 9/11/25 at 8:10 A.M., he/she had weakened knees that buckled resulting in staff lowering him/her to ground. out 21 sampled residents. The facility resident census of 98 residents. A policy related to Notification of Change was requested not received at time of exit. 1. Review of Resident #54's admission Record form showed the resident was admitted on [DATE] with diagnoses of:-History of falls. -Cerebral Infraction (stroke happens when there is a loss of blood flow to part of the brain). -Cognitive Communication Deficit (condition where a person has difficulty with communication because of a disruption in brain function that affects thinking abilities). -The resident was his/her own person, and a family member was his/her first emergency contact. Review of the resident's Health Status Note dated 9/11/25 at 8:10 A.M, showed:-This nurse was notified by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, the facility failed to maintain one mechanical lift in resident room [ROOM NUMBER], free from a buildup of grime and particles. This practice affected one resident who was dependent on the use of a mechanical lift. The facility census was 98 residents.Review of the facility's Undated guidelines for inspecting the mechanical lifts, entitled Inspecting Mobile lifts, showed: -Inspect all surfaces on lifts to ensure they are in good repair.-Clean as necessary and notify housekeeping.-Check battery if applicable.-Inspect the control panel.-Inspect the electrical cords.1. Observations on 9/23/25 at 11:52 A.M. and on 9/25/25 at 12:58 P.M., showed a buildup of grime on the base of the mechanical lift in the resident's room. During an interview on 9/25/25 at 12:53 P.M., Certified Nursing Assistant (CNA) A said the mechanical lift should be cleaned every shift and the facility staff who used the mechanical lift should clean the lift more often. During an interview 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 · D2025-11-18 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one sampled resident (Resident #18) out of 21 sampled residents. The facility census was 98 residents. A call light policy was requested and not provided at the time of exit. 1. Review of Resident #18's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/30/25 showed:-The resident was moderately cognitively impaired. -Required staff assistance with his/her activities of daily living. Review of the resident's care plan dated 9/24/25 showed:-The resident was at risk for falls related to unsteady gait and cognitive impairment with poor safety awareness.-The resident had limited physical mobility.-The resident would have interventions in place to reduce the risk for falls and/or injury r/t falls through the next review period that included:--Display a Call Don't Fall sign.--Educate resident to ask staff for assistance.--Educate resident to use the call light to ask for assistance.--Be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-18 · 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
Based on observation, interview and record review, the facility failed to ensure infection control practices for proper placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) tubing from dragging or touch the ground, for one sampled resident (Resident #10) who's at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 21 sampled residents. The facility census was 98 residents. Review of the facility Indwelling Foley Catheter Care policy dated 12/2024 showed: -Ensure resident to keep the catheter and tubing free of kinks. -Check drainage tubing and bag to ensure that the catheter is draining properly. 1. Review of Resident #10 admission Record showed the resident admitted to the facility with a diagnosis of obstructive and reflux uropathy (is kidney scarring caused by urine flowing backward from the bladder into a ureter and toward a kidney).Review of the resident's Catheter Care Plan dated 5/6/25 showed:-The resident required a foley catheter due to diagnosis of obstructive and reflux…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 that one sampled resident (Resident #1) out of four sampled residents received medications as prescribed by the physician. On 7/9/25 Certified Medication Technician (CMT) A failed to verify the identity of the residents prior to administering medication and failed to update the resident's bed location in the electronic medication administration (eMAR) system, resulting in Resident #1 receiving Resident #2's medications. The facility census was 95 residents.On 7/21/25 the facility Administration was notified of the past noncompliance which occurred on 7/9/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/10/25. Review of the facility's Medication Pass Tips policy dated 5/19 showed:-The five rights: right drug; right time; right resident; right dose; right route.-Prior to preparing medication, verify 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 · D2025-07-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when one staff member (Dietary Manager) spoke in a harsh tone and showed aggression to one sampled resident (Resident #2). The facility census was 97 residents. On 7/9/25 the facility Administration was notified of the past noncompliance which occurred on 6/18/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/7/25. A facility policy for dignity and respect was requested but not provided.1. Review of Resident #2's admission Record, showed:-The resident was admitted to the facility on [DATE].-The resident had a diagnosis of need for assistance with personal cares.-The resident had a diagnosis of dysphagia (difficulty in swallowing).-The resident had a diagnosis of cognitive communication deficit (a person has difficulty communicating because of injury to the brain that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free from significant medication errors when staff administered the wrong medications to one sampled resident (Resident #1) out of six sampled residents. The facility census was 95 residents. On 2/4/25 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 1/31/25. On 1/31/25 the facility Administrator was notified of the incident and the investigation was started. Certified Medication Technician (CMT) A notified Licensed Practical Nurse (LPN) A of an medication error he/she had made. CMT A and all nursing staff were educated on medication administration on 1/31/25. The deficiency was corrected on 1/31/25. Review of the facility Medication Pass Tips dated 5/2019 showed: -The following is a compilation of points to keep in mind during medication pass. -Prior to preparing medications, verify the resident's identity. -A photo is available on the electronic Medication Administration Record (eMAR). -Another staff member who is familiar with 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 · D2024-05-09 · 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 ensure appropriate transfer techniques were utilized for two sampled residents (Resident #1 and #3) out of four sampled resident. The facility census was 94 residents. Review of the facility's Transfer-One Person Skills Checklist: -Check [NAME] for appropriate transfer technique. -Position chair, wheelchair, commode to resident's strong side. -Assist resident to sitting position with feet firmly on the floor. -Apply gait belt. -Have resident place their hands on you shoulders. -If transferring from chair, wheelchair, commode, have resident place hands on arm rests and push up while you pull resident up to a standing position. -Brace knees against resident's knees, or your knees on the outside of the resident's knees to block feet from sliding. -Ask resident to lean forward, count to three and ask resident to push up with legs while you pull resident to a standing position. 1. Review of Resident #1's admission Record showed 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 · Ecited before2024-01-08 · 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 and interview, the facility failed to maintain the ceiling fans in the South nurses' station sitting area, free of a buildup of dust and failed to maintain the tube feeding poles in resident rooms [ROOM NUMBERS] free of debris on those poles. This practice potentially affected at least 10 residents who used the sitting area and two other residents who received tube feedings. The facility census was 92 residents. Observation on 1/5/23 at 9:45 A.M. with the Maintenance Director showed a buildup of dust on the ceiling fans over the South Nurses' station sitting area. During an interview on 1/5/23 at 9:47 A.M. the Maintenance Director said the housekeepers have extendable cleaners they can use to clean the fans. During a phone interview on 1/9/23 at 2:12 P.M., the Housekeeping Area Account Manager said he/she expected the Maintenance Personnel to clean the fans due to the height of the fans. 2. Observations on 1/2/24 at 9:46 A.M. and at 1:12 P.M., on 1/3/24 at 10:32 and A.M., and on 1/8/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · E2024-01-08 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two sampled residents (Resident #31 and #80) who had a weight loss of over 10% in the last six months; to ensure monitoring of weight loss interventions was completed to try to prevent continued weight loss for one sampled resident (Resident #80); to ensure health shake supplements were documented to show the amount consumed for three sampled residents (Resident #80, #53 and #81) and to ensure dietary orders were transcribed accurately to dietary meal tickets for two sampled residents (Resident #53 and Resident #81) out of 21 sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Nutrition (impaired)/Unplanned Weight Loss- Clinical Protocol dated January 2017 showed: -The nursing staff were responsible for the monitoring and documenting of weights. -The threshold for significant unplanned weight loss was: --One month: 5% loss was significant,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-08 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% with a medication error rate of 26.92% when Licensed Practical Nurse (LPN) B did not ensure all crushed medication substances in medicine cups were dissolved and given via percutaneous endoscopic gastrostomy (PEG - a tube is a procedure to place a feeding tube) for one sampled resident (Resident #76) and when Registered Nurse (RN) A did not ensure that insulin pens were primed before insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. Review of the facility Enteral feeding Policy dated 1/22 showed: -Flush tubing with with at least 30 ml (milliners) of water or prescribed amounts before and after feedings. -No instruction for administration of medication via feeding tube. Review of the facility policy general dose preparation and medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained at the appropriate temperature in the North Hall medication room which had the potential to affect all residents in the North Hall. The Facility census was 92 Rresidents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges including: --Refrigeration: 36 degrees to 46 degrees Fahrenheit (F). -Facility should monitor cold storage containing vaccines two times a day per Centers for Disease Control (CDC) guidelines. 1. Review of the North Hall's Refrigerator Temperature Log dated January 2024 showed: -The temperature on 1/1/24 was 38 degrees F. -The temperature on 1/2/24 was 38 degrees F. -The temperature on 1/3/24 was 39 degrees F. -The temperature on 1/4/24 was not legible. Observation on 1/5/24 at 12:40 P.M. of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the door to the dessert fridge closed properly; to ensure the baffle (movable metal partitions used to create slotted openings along the back of the hood used to direct the air that is being exhausted out of the hood) were installed in the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease), vents did not have a heavy buildup of dust; and to ensure the upper water nozzles of the dishwasher were maintained free from debris inside those nozzles. This practice potentially affected 90 residents who received food from the kitchen. The facility census was 92 residents. 1. Observation during the initial kitchen observations on 1/02/24 from 9:03 A.M. through 9:20 A.M., showed: - The door to the dessert fridge did not close properly without closing it extra hard with the body. - A buildup of dust on the range hood baffle vents while there was food cooking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-08 · 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, the facility failed to ensure proper hand hygiene during medication pass when passing oral medications and connecting/disconnecting an intravenous (IV) antibiotic to two sampled resident's (Resident #24 and #40) central venous catheter (CVC- a catheter placed in a large vein usually in the chest, neck, or groin to give medications, fluids, nutrition, or blood); during insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48); and to follow appropriate infection control practices to properly change gloves and wash or sanitize their hands during incontinence care for two sampled residents (Resident #59 and #70) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. Review of the facility's policy titled Standard Precautions-Hand Hygiene dated from 2019 showed: -Appropriate hand hygiene is essential in preventing transmission of infectious agents. -Hand hygiene continues…
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 · D2024-01-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medicine kept in a resident room was properly stored; to ensure there was a physician's order for self-administration of medication, and to ensure the resident was assessed to be able to self-administer medications for one sampled resident (Resident #21) and one supplemental resident (Resident #27) out of 21 sampled residents and 4 supplemental sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. -Facility should store bedside medications or biologicals in a locked compartment within the resident's room. 1. Review of Resident #27's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by…
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 before2024-01-08 · 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 perform a safe transfer for one sampled resident (Resident #80) who needed assistance with transfers and was unable to bear weight, and to ensure the resident was not left sitting up in his/her wheelchair unattended in his/her room to prevent falls out of 21 sampled residents. The facility census was 92 sampled residents. Review of the facility Fall Management policy and procedure revised 9/17/19, showed the purpose of the fall management program was to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promotes safety, prevention and education of both staff and residents. -The fall policy did not include documentation showing how residents should be transferred using a gait belt or with one or two person assistance. -The fall policy did not show documentation regarding how fall…
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 before2024-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents with oxygen had physician's orders documented for two sampled residents (Resident #70 and # 83); to ensure oxygen nasal cannulas (a thin flexible tube that gives you additional oxygen through your nose), face masks and tubing was kept covered when not in use for one sampled resident (Resident #83) and ensured free standing oxygen containers were secured in an oxygen stands for two sampled residents (Resident #70 and #83) out of 21 sampled residents. The facility census was 92 residents. Review of the facility's Oxygen Administration policy and procedure dated 1/2027, showed: -Verify that there is a physician's order for this procedure of oxygen administration. -After completing the oxygen set up or adjustment the following should be documented in the resident's medical record: the rate of oxygen flow rate, frequency and duration of treatment, and the reason for as needed administration. -There was no documentation that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-10 · 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, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBCs), and/or the Nurse Aide (NA) Registry were completed and to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for nine out of nine sampled employees. The facility census was 86 residents. Record review of the facility's Abuse, Prevention and Prohibition policy last reviewed 2021 showed: -The facility would not knowingly employee individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. -All employees would have CBCs, State and Federal required background checks. 1. Record review of Employee A's employee file showed: -The employee was hired on 5/23/22 as a Certified Nursing Assistant (CNA). -The EDL check was completed on 6/3/22. -The CBC was completed on 6/3/22. -The FI check was not dated when completed. Record 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 before2022-06-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen, nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) and/or Continuous Positive Airway Pressure (CPAP-a device that delivers continuous pressurized air through tubing into a mask that you wear while you sleep) equipment was stored using proper infection control practices when not in use for three sampled residents (Resident's #56, #72, and #22) out of 18 sampled residents. The facility census was 86 residents. A policy was requested and the facility did not have a policy on respiratory equipment storage. 1. Record review of Resident #56's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acute respiratory failure (occurs when fluid builds up in the air sacs in your lungs). -Congestive Heart Failure (CHF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). Record…
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 before2022-06-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to meet sanitary conditions and practice sanitary procedures for food and non-food contact surface areas before, during and after food preparation tasks. This deficient practice of not keeping food and non-food contact surfaces sanitary could, potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partake of the meals prepared by the dietary staff. The facility census was 86 residents at the time of the survey. 1. Observations on 6/6/22 at 8:25 A.M. during an initial brief tour of the kitchen and on 6/8/22 between 5:17 A.M. and 12:10 P.M. in the kitchen during the facility's kitchen inspection, showed the following: -On 6/6/22 and on 6/8/22, the juice dispensing equipment consisting of one hand-held gun with one nozzle connected to three different beverage tubes. -All of the beverage tubes were dispensed through the one dispensing gun's nozzle. -The flavors of beverages dispensed through the tubing were an orange blend, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 notify the resident's physician when medications were not administered as ordered for one sampled resident (Resident #283) out of 18 sampled residents. The facility census was 86 residents. Record review of facility policy titled Significant Condition Change and Notification dated May 2019 showed: -To ensure that the residents family and/or representative and medical practitioner were notified of a residents change such as medication error. -The licensed nurse would contact the medical practitioner about the medication error. -Prior to medical practitioner being called the nurse will have completed the Situation-Background-Assessment-Recommendation (SBAR) assessment. -Each attempted call will be documented as to the time called, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to be called. If…
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 · D2022-06-10 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) for two sampled residents (Resident's #9 and #41) who were discharged from Medicare Part A services and remained in the facility out of three sampled residents. The facility census was 86 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C-09-20) dated 1/9/09 showed: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons. -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment 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 · Dcited before2022-06-10 · 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 ensure medications were observed taken prior to the nurse leaving the room and not left at bedside for two sampled residents (Resident's #20 and #21) who had not been assessed by the Interdisciplinary Team (IDT - attending physician, Registered Nurse (RN) with responsibility for the resident, and other staff deemed appropriate, and the resident and/or resident representative) for their cognitive and physical abilities to safely self-administer medication and for whom there was no care plan showing either resident had the ability to fully or partially self-administer medications out of 18 sampled residents. The facility census was 86 residents. Record review of the facility's Medication Administration policy, dated May, 2019 showed: -Staff were to administer medications safely and appropriately. --Give the resident the medication. --Remain with the resident to ensure the medication is swallowed. --Return medication to the cart and document…
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 · D2022-06-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and administer a resident's ordered medication for one sampled resident (Resident #283) out of 18 sampled residents. The facility census was 86 residents. Record review of facility policy entitled Medication Administration dated May 2019 showed: -Circle initials on Medication Administration Record (MAR) if medication was not administered as ordered and record a reason in the PRN/Omission section of the MAR. -If medication was ordered but not present, call the pharmacy or the supervisor to obtain the medication. 1. Record review of Resident #283's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acute respiratory failure. -Essential (Primary) Hypertension (high blood pressure). -Congestive Heart Failure (CHF - disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 TUTERA SENIOR LIVING & HEALTH CARE — 25 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 | 2.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 2.2 | +1.8 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 24 homes this chain runs (chain average 2.0★, 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 |
|---|---|---|---|---|
| TUTERA GROUP HEALTHCARE MANGEMENT, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 05/25/1994 |
| BARR, SHIRLEY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 05/25/1994 |
| TUTERA GROUP, INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 05/25/1994 |
| BROOKS, KILEY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2022 |
| WALNUT CREEK MANAGEMENT COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2008 |
| TUTERA, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/25/1994 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265579. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, 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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