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Capitol River Wellness & Rehabilitation

1221 Southgate Lane, Jefferson City, MO 65110 · For profit - Limited Liability company · 120 certified beds · (573) 635-3131 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0567)1 immediate-jeopardy citation$14,446 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0567)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $14,446 in federal fines (most recent 2023-09-29)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
1511 Christy Dr · (844) 853-8937 · Call to confirm hours
Pharmacy
724 Stadium West Blv · (573) 635-8384 · Call to confirm hours
Grocery
724 Stadium West Blv · (573) 718-0276 · Call to confirm hours
Park
1232 Jefferson St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 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 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.6%18.1%15.4%typical
Long-stay residents who lose too much weight1.6%5.3%5.4%better
Long-stay residents with a catheter left in their bladder1.6%1.1%0.9%worse
Long-stay residents with a urinary tract infection1.5%2.3%2.0%better
Long-stay residents with depressive symptoms11.5%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.4%4.1%3.3%worse
Long-stay residents whose ability to walk worsened14.4%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.8%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine96.5%90.9%95.3%typical
Long-stay residents with pressure ulcers6.7%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control18.2%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table21.7%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.1%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine40.4%63.5%79.4%worse
Short-stay residents rehospitalized after admission17.0%26.0%22.6%better
Short-stay residents with an outpatient ER visit6.8%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.592.111.67typical
Long-stay outpatient ER visits per 1,000 resident days1.952.331.80typical

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.

43.5% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.5%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
63.0%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 63.0% 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 27 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 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.5%CMS range 32.9–58.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.5–13.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge70.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay5.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 4.5–15.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.36
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.37
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.19
RN hoursweekends
64.5%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 73.9 residents a day — about 62% occupied, or roughly 46 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 3.86 on weekdays — 17% thinner on weekends. RN hours go from 0.43 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-05-21)
4
at the previous standard inspection (2024-12-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interview and record review, the facility staff failed to provide 24-hour protective oversight for one sampled resident (Resident #1) when they failed to conduct visual checks on the resident on 09/22/23 from 6:45 P.M. to 8:26 A.M. At that time, staff found the resident in his/her room on the floor with blood on his/her hands and face. Hospital staff determined the resident suffered a fracture to the right sixth rib. Facility census was 93. The Administrator was notified on 9/27/23 at 4:23 P.M., of an Immediate Jeopardy (IJ) which began on 9/22/23. The IJ was removed on 9/24/23 as confirmed by surveyor onsite verification. 1. Review showed the facility did not have a policy on monitoring or rounding on residents. During an interview on 9/26/23 at 12:55 P.M., the administrator said the facility did not have a policy on monitoring or rounding on residents, but staff followed standard practices. This included completing walking rounds from room to room, at the beginning of each shift. Staff should continue to check on residents at least every two hours until the next shift…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to maintain a comfortable and homelike environment. The facility census was 84. 1. Review of the facility policy titled, Maintenance Services, dated August 2020, showed the Maintenance Department is responsible for maintaining the building in compliance with current federal, state, and local, regulations, and guidelines. The Director of Maintenance is responsible for conducting regular inspections of hallways and activity areas. 2. Observation on 05/19/26 at 8:36 A.M., showed the memory care unit walls below the handrails, unpainted, and missing baseboard with exposed screws. 3. Observation on 05/19/26 at 10:56 A.M., showed the main dining walls with missing base trim, exposed unfinished and unpainted drywall. 4. Observation on 05/19/26 at 10:59 A.M., showed the 100 and 300 hallway walls with missing base trim and a large hole in the drywall between rooms [ROOM NUMBERS]. 5. Observation on 05/19/26 at 12:29 P.M., showed kitchenette in the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-21 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to provide written information to the residents and/or the residents' representative of the bed hold policy at the time of transfer to the hospital for eight residents (Resident #8, #12, #28, #47, #67, #71, and #86) out of 23 residents sampled. The facility census was 84. 1. Review of the facility policy titled, Bed Hold, dated June 2020, showed the facility notifies the resident or his/her representative, in writing, of the bed hold policy any time the resident is transferred to general acute care hospital. 2. Review of Resident #8's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and had not returned. The medical record did not contain documentation staff provided the bed hold policy upon discharge to the resident or the resident's responsible party. 3. Review of Resident #12's medical record showed staff documented the resident discharged from the facility to the hospital on [DATE] and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-21 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, facility staff failed to complete a baseline care plan within 48 hours of admission for six residents (Resident #8, #35, #62, #67, #71, and #86) out 23 sampled residents. The facility census was 84.1. Review of the facility's policy titled Care Planning, dated 06/2020, showed the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission and will include at least the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. 2. Review of Resident #8's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan was not completed.3. Review of Resident #35's medical record showed staff documented the resident admitted to the facility on [DATE]. Review of the record showed a baseline care plan completed on 03/04/26.4. Review of Resident #62's medical record showed staff documented the resident admitted…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-21 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for four residents (Resident #5, #9, #71, and #83) who used bed rails out of 23 sampled residents. The facility census was 84. 1. Review of the facility's policy titled Bed Rails, dated 06/2020, showed: -Before installing a bed rail, the facility must assess the resident for risk of entrapment from bed rails and ensure the beds dimensions are appropriate for the resident's size and weight; -Maintenance/Designee will assess the bed dimensions no less than quarterly; -Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or become loose over time. The facility policy did not address zone measurements for risk of entrapment. 2. Review of Resident #5's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/06/26, showed staff documented bed rails not used. Review of the resident's care plan, dated 03/08/26, showed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure sanitary conditions for a urinary drainage bag (a bag attached to a tube that holds urine) when staff failed to keep the drainage bag off the floor for three residents (Resident #5, #58 and #34) out of three sampled residents. The Facility census was 84. 1. Review of the facility policy titled, Catheter-Care of, dated June 2020, showed catheter collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. Take care to ensure the collection bag does not touch the floor at any time. 2. Review of Resident #5's Annual Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 03/06/26, showed staff assessed the resident with an indwelling urinary catheter. Review of the resident's care plan, dated 04/09/26, showed the resident required a Foley Catheter (a flexible, sterile tube inserted into the bladder to continuously drain urine) and directed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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, facility staff failed to ensure two resident's (Resident #1 and #2) were allowed to exercise resident's rights when staff opened their mail without the resident's present. The facility census was 81. 1. Review of facility's resident bill of right's policy, dated November 2016, showed residents have the right to send and receive mail promptly and unopened. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/12/25, showed staff assessed the resident as cognitively intact. During an interview on 4/28/25 at 10:00 A.M., the resident said the business officer manager (BOM) opened his/her mail in his/her office and then came in his/her room on 4/24/25. He/She has an audio conversation with the BOM where the BOM said he/she opens residents mail that comes from places like Medicaid and disability because it may affect the residents billing. He/She said he/she asked the BOM for the envelope to see who the envelope was addressed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-04 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document they provided colostomy care for one resident (Resident #1), catheter care for one resident (Resident #2), monitor blood glucose levels for one resident (Resident #3), or obtain weights for one resident (Resident #4) out of four sampled residents. The facility census was 81. 1. Review of the facility's Colostomy Care policy, dated 08/2017, showed staff were directed to document on treatment sheet care completed. Review of the facility's Weights policy, dated 10/2009, showed staff were directed to electronically document weights. The facility did not provide a policy in regard to catheter care or blood glucose monitoring documentation guidance. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/20/24, showed staff assessed the resident as follows: -Cognitively intact; -Did not reject care; -Used an ostomy bag (a surgical…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-04 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 81. 1. Review of the Facility Assessment, dated 08/02/24, showed staff are directed as follows: -Direct care staff required to care for their facility census for an eight hour shift should include: Three day nurses, three evening nurses, three night nurses, six day Certified Nurse Aides (CNA's), six evening CNA's, five night CNA's, and two day shower aide's. -The assessment is based on the resident population and their healthcare needs and support; -The average daily census number of occupied beds was 88. Review of the employee staffing schedule from 02/01/25 through 02/28/25, with an average daily census of 88, showed: -Saturday 02/01/25- zero day shower aides, two evening nurses and five CNA's; -Monday 02/03/25- zero day shower aides and four night CNA's; -Wednesday 02/05/25- five day CNA's and zero day shower aides; -Thursday 02/06/25- one day shower aide and two night nurses; -Friday 02/07/25- five…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility census was 85 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2016. showed: -Food shall be stored on shelves in a clean, dry area, free from contaminants; -Foods shall be stored at proper temperatures and using appropriate methods to ensure the highest level of food safety; -Label food items held for longer than 24 hours with the name of the food, if not in original packaging, and the date by which it should be sold,consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing proper refrigeration (at a temperature that ensures the internal temperature of the food is 41 degrees Fahrenheit or below); -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Store raw animal foods, such as eggs, meat, poultry,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-19 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to prevent the commingling of 32 resident's (Resident #8, #9, #12, #17, #19, #20, #21, #22, #23, #27, #32, #35, #39, #43, #44, #46, #49, #52, #60, #65, #71, #78, #87, #89, #90, #91, #92, #93, #94, #95, #96, and #97) personal funds with the facility operating funds out of 85 sampled. The sampled residents resided in the facility. The facility census was 85. 1. Review of the facility's policy titled Collections Guidelines, undated, showed: -Requests for a refund that is a result of a credit balance on the resident's account; -Resident refunds are requested based on the following; -When a resident has discharged the facility with no anticipation of returning; -When an overpayment of funds was applied to the account and a refund is requested by the resident or responsible party; -Third Party Refunds are requested based on the following; -When a Third-party payer has made an overpayment in comparison to the amount that was billed; -When a resident has died…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Ecited before2024-12-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, and ceilings of resident occupied rooms and common areas. The facility census was 85. 1. Review of the facility's policy titled Housekeeping Cleaning Procedures: Resident Room Cleaning, dated June 2018, showed staff were directed as follows: -Dust mop and damp mop floor; -Damp mop restroom floor using microfiber flat mop; -Weekly procedure to remove mineral deposits from sink and tub/shower; -Wipe walls. Review of the [NAME] Side and East Side Housekeeper checklist, undated, showed staff were directed as follows: -Remove trash, sweep and mop, spot clean walls, sweep and mop room last and leave a wet floor sign; -Mondays- dust over head lights and blinds and bathroom fans; -Tuesdays- clean filters on Packaged Terminal Air Conditioner units. Review of the environmental checklist for room cleaning, undated, showed staff were directed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, facility staff failed to respect the dignity of two residents (Resident #22 and #24) out of 22 sampled residents during meal time. The facility census was 85. 1. Review of the policy titled The Dining Experience: Staff Roles, dated 2016, showed staff will be discouraged from standing over the resident while assisting them to eat and staff will promote resident dignity in the dining room. Review of the facility policy titled Resident [NAME] of Rights, reviewed January 2015, showed residents will be treated with consideration to respect, and full recognition to the residents dignity. 2. Observation on 12/16/24 at 8:46 A.M., showed Resident #22 and Resident #24 in the dining room at the same table. Observation showed Certified Nurse Aide (CNA) M placed meal trays in front of Resident #22 and Resident #24. CNA M stood over the residents, while he/she assisted them with bites of food. During an interview on 12/16/24 at 8:46 A.M., CNA M said Resident #22 and Resident #24 are feeders and are hard to manage with only two CNA's working. 3. Observation 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-08 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 87. 1. Review of the facility's Organizational Plan and Roles of Key Staff policy, dated 2016, showed The Director of Food and Nutrition Services credentials will follow state regulations. The Director of Food and Nutrition Services credentials may include a Sanitation Certification, a 90-hour approved Dietary Manager's Course, or a two or four year degree in nutrition or food service as approved by the state. Review of the dietary manager's (DM) personnel records, showed a hire date for the DM position listed as 11/19/23. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 02/05/24 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-08 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to reheat pureed food items in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. The facility staff also failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (º F) or higher upon service to the residents. The facility census was 87. 1. Review of the facility's Monitoring Food Temperatures for Meal Service, dated 2016, showed: -Prior to serving a meal, food temperatures will be taken and documented for cold and hot foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below; -If the serving/holding temperature of a hot food item is not at 135º F or higher when checked, they will be reheated to at least 165º F for a minimum of 15 seconds, only once and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff failed to properly sanitize manually washed kitchenware to prevent cross-contamination. The facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff also failed to maintain food delivery equipment in a clean and sanitary manner to prevent the growth of food-borne pathogens and prevent cross-contamination. The facility census was 87. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2016, showed: -All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines; -All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between tasks; -Employees will wash hands…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, trim, handrails, and windows in good repair. The facility census was 87. Review of the policies provided by the facility did not contain a policy for environmental concerns. 1. Review of the Maintenance Clipboard, showed it did not contain maintenance requests for the disrepair listed below. 2. Observation on 02/05/24 at 9:51 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with chipped paint. Observation showed the corner by the bathroom with chipped paint and exposed drywall. 3. Observation on 02/05/24 at 9:56 A.M. showed the 100 Hall walls and handrails with black marks. Observation showed between room [ROOM NUMBER] and 106 trim with the wood chipped off. 4. Observation on 02/05/24 at 10:06 A.M., showed resident occupied room [ROOM NUMBER] wall behind the headboard of the bed with areas 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-08 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for nine residents (Resident #4, #6, #10, #31, #46, #58, #83, #92, and #302). The facility census was 87. 1. Review of the facility's policy, titled Comprehensive Person Centered Care Plans, dated March 2018, showed staff were directed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The comprehensive person centered care plan shall be fully developed within seven days after completion of the admission Minimum Data Set (MDS) Assessment, a federally mandated assessment tool to be completed by facility staff; -The interdisciplinary team (IDT) along with the resident and/or Resident representative will identify resident problems, needs, strengths, life history, preferences and goals; -For each problem, need, or strength a resident-centered…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-08 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Based on observation, interview, and record review, facility staff failed to meet professional standards of care when staff failed to document neurological checks and fall follow-up for six residents (Resident #18, #46, #50, #58, #67, and #302), and failed to ensure physicians orders were followed for two residents (Resident #18, and #302). The facility census was 87. 1. Review of the facility's policy titled Accident and Incident Documentation and Investigation Resident Incident, revised 07/2018, showed staff are directed to do the following: -Licensed Nurse assigned at the time of the resident care accident/incident is responsible for documenting the incident in the resident's medical record; -Nurse's notes could contain the following documentation: Date and time of incident; Clear, objective facts of what happened; An evaluation of the resident's condition at the time of the accident/incident including vital signs, physical characteristics apparent as a result of the accident/incident; 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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, facility staff failed to follow up on Urinalysis and Culture with Sensitivity (UA C&S) (lab work to rule out Urinary Tract Infection (UTI) and begin treatment timely for two residents (Resident #18 and #50). The facility census was 87. 1. Review of the facility's policy titled Surveillance for Healthcare Associated Infections, revised 09/2019, showed it is the responsibility of the Director of Nursing (DON), Infection Control Designee, Licensed Nurse to report suspected infections to the physician and obtain a diagnosis. Review of the facility's policy titled Laboratory Tests, revised 11/2017, directed staff as follows: -Lab tests are completed as ordered by the physician or physician extender (Nurse Practitioner (NP), Physician Assistant (PA), or Clinical Nurse Specialist (CNS)); -Licensed Nurse, or designee, shall obtain the labs ordered by the physician, complete the lab requisition form, and add the information to the Lab Scheduling/Tracking form; -Any…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, for one residents (Resident #67) when staff failed to accurately assess the residents' falls. The facility census was 87. 1. Review of the policies provided by the facility did not contain a policy for MDS assessments. 2. Review of the Resident Assessment Instrument (RAI) manual, dated 10/2023, showed staff are directed as follows: -Annual MDS Assessment Reference Date (ARD) must be set within 366 days of the previous comprehensive assessment; -Use the RAI manual to increase the accuracy of assessments; -Coding fall history on admission: look back 180 days prior to admission; -Coding a fall any time in the last month: code 0 for no fall; code 1 for a fall; code 9 for unable to determine; -Coding a fall anytime in the last two to six months: code 0 for no fall; code 1 for a fall; code 9 for unable to determine. 3. Review of Resident #67's admission MDS,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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, facility staff failed to remove and destroy discontinued and outdated medications. The facility census was 87. Review of the facility's policy titled Medication Storage, dated November of 2010, showed outdated medications are to be removed from storage on a continual basis. 1. Observation on 02/07/24 at 10:45 A.M., showed the Memory Care Unit (MCU) medication cart contained: -PROAIR HFA (to treat or prevent bronchospasm) 90 Micrograms (mcg) Inhaler with an expiration of 02/2024; -Hydroxyzine HCL (Hydrochloride) 25 milligrams (mg) tablets, dated 09/12/22; -Hydroxyzine HCL 25 mg tablets with an expiration date of 09/16/23; -Prochlorperazine (treat nausea and vomiting)10 mg tablets, with an expiration date of 06/7/23; -Ondansetron (prevent nausea and vomiting) 4 mg tablets with an expiration date of 11/15/23; -BUT-APAP-CAFF 50-300-40 (used for headaches) with an expiration date of 09/2/23. During an interview on 02/07/24 at 11:28 A.M., Licensed Practical Nurse (LPN) AA said he/she is not sure how the medication carts are cleaned. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #10). The facility census was 87. 1. Review of the facility's policy titled Hand Washing, revised 09/2019, showed staff were directed to use proper hand washing technique to prevent the spread of infection. 2. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/29/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Rejection of care not exhibited; -Maximal assist from staff member for personal hygiene; -Stage 4 pressure ulcer; -Indwelling catheter; -Ocassionally incontinent of bowel; -Dependent on staff member for bathing. Observation on 02/05/24 at 10:22 A.M., showed the wound nurse entered in Resident #10's room to provide wound care. Licensed Practical Nurse (LPN) J entered the resident's room, washed his/her hands and donned his/her gloves, then doffed gloves and left room to get a brief for the resident. The wound nurse washed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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, facility staff failed to notify one resident's (Resident #1) responsible party when the resident had a fall with injury and transprted to the hospital for treatment. The facility was census 91. 1. Review of the facility's resident incident policy, dated July 2018, showed staff are directed to document any contacts made or attemptes made with the resident's physician, family, legal representative, or any other health care professional or person involved with the resident's care. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/23/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -At risk for falls with a fall in the past two to six months prior to admission; -Diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and unsteadiness on feet. Review of the resident's plan of care, dated August 2023, showed staff assessed the resident at risk…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have adequate nursing staff available to meet the needs of the residents on the Memory Care Unit (MCU), as determined by their facility assessment. Review showed only one Nurse Aide (NA) worked on the MCU on the night shift of 9/22/23 responsible for the care of 23 residents during the shift when the facility assessment showed the general staffing plan for direct care staff would require a ratio of one staff to ten residents at the least, and a ratio of one staff to 20 residents at most. Facility staff did not check on one resident (Resident #1) who resided on the MCU at all during the night shift of 9/22/23 into 9/23/23. The facility census was 93. 1. Review of the Facility Assessment, dated 1/10/23, showed the number of staff required to care for their facility resident census as follows: -Night shift required one Licensed Nurse per 20 residents; -The facility general staffing plan for direct care staff with a ratio of one staff to ten residents at the least and a ratio of one staff to 20 residents at most. Review of the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$14,446 in federal fines across 1 penalty.

  • $14,446 — penalty dated 2023-09-29

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NORBERT BENNETT & DONALD DENZ — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:

RatingThis homeChain avg
Overall 2 of 51.5+0.5 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 1 of 51.0≈ chain avg
Quality measures 4 of 52.5+1.5 vs chain
The other 1 home this chain runs (chain average 1.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
D&N, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 12/31/2004
DTD HC LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 12/31/2004
DONALD T DENZ IRRV TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 05/23/2008
NORBERT A BENNETT IRRV TR FBO CHILDRENOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST12%since 05/23/2008
NORBERT A BENNETT IRRV TR FBO GRANDCHILDRENOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 05/23/2008
BENNETT, NORBERTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST32%since 10/04/2004
DENZ, DONALDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST44%since 10/04/2004

5 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.

$8.1M
Net patient revenuemost recent cost report
-13.3%
Operating marginrevenue minus expenses
$1.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 9%Other / private 23%

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$290per resident / day
operating cost
$8,822per month
≈ monthly operating cost
$256per day
avg. revenue, all payers

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

What families pay in MO

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265530. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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