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Joplin Gardens

2810 South Jackson Avenue, Joplin, MO 64804 · For profit - Limited Liability company · 92 certified beds · (417) 572-0041 Medicare & Medicaid certified

Call the home — (417) 572-0041 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • 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 independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)
  • about 32% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3126 S Jackson Ave · (417) 208-3465 · Call to confirm hours
Pharmacy
1102 W 32nd St · (417) 347-3792 · Call to confirm hours
Grocery
Aldi0.5 mi
2630 McClelland Blvd · (855) 955-2534 · Call to confirm hours
Park
2800 Saint Johns Blvd · (417) 625-4750 · Typically dawn to dusk
Place of worship
2415 S Moffet Ave · (417) 623-3333

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 rating1★
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 increased23.7%18.1%15.4%worse
Long-stay residents who lose too much weight4.5%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.3%1.1%0.9%better
Long-stay residents with a urinary tract infection3.9%2.3%2.0%worse
Long-stay residents with depressive symptoms0.0%18.5%6.5%check this — see note marked star 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 injury9.9%4.1%3.3%worse
Long-stay residents whose ability to walk worsened23.4%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication27.0%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.4%90.9%95.3%typical
Long-stay residents with pressure ulcers7.0%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control21.0%17.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.2%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine76.1%63.5%79.4%typical
Short-stay residents rehospitalized after admission34.5%26.0%22.6%worse
Short-stay residents with an outpatient ER visit18.3%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.242.111.67worse
Long-stay outpatient ER visits per 1,000 resident days2.892.331.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

55.7% 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 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.7%U.S. median 51.5%
Got home and stayed home
13.2%U.S. median 10.7%
Went back to hospital
48.5%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 48.5% 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 68 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 SNF55.7%CMS range 46.0–63.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.2%CMS range 9.4–18.310.7%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 discharge48.5%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 discharge54.4%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 discharge38.2%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 identified88.3%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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.9%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 worsened1.0%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 hospitalization6.6%CMS range 3.5–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 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

0.21
RN hours/ resident / day
1.10
LPN hours/ resident / day
1.76
Aide hours/ resident / day
3.08
Total nurse hours/ resident / day
0.15
RN hoursweekends
61.9%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 92 beds and averages 78.0 residents a day — about 85% occupied, or roughly 14 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.85 hrs/resident/day on weekends vs 3.17 on weekdays — 10% thinner on weekends. RN hours go from 0.24 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2024-08-23)
8
at the previous standard inspection (2022-09-13)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

  • Actual harm · Gcited before2026-03-17 · 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 record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when staff failed to follow the care plan regarding the use of a mechanical lift for a transfer resulting in one resident (Resident #1) suffering a fracture to the upper arm. A sample of six residents was reviewed for transfer safety. The facility census was 76.On 02/17/26, the Administrator and Director of Nursing (DON) were notified of the Past Non-Compliance that occurred on 02/16/26, at 10:30 A.M., which resulted in injury to Resident #1. On 02/17/26, the Administrator completed a root cause analysis and investigation into the incident and educated employees involved. The Administrator and DON in-serviced all employees regarding company expectations and policies for resident transfers, including following care plans pertaining to the use of mechanical lifts or gait belt assist for transfers. The noncompliance was corrected on 3/10/26. Review of the facility's policy entitled Hydraulic Lift (Hoyer Lift), undated showed the following:-Follow the…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2026-01-23 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — the official record, unedited, may be distressing

    This citation is uncorrected. For prior example please see Event ID 1D8649-H1, exit date 12/12/25.1.Please refer to event 1D8649-H2, exit date 01/23/26, for details. Complaint #2718425

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-23 · tag F0725 — failed to have enough nursing staff — pattern
    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 — the official record, unedited, may be distressing

    Deficiency Text Not Available

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 79.Review showed the facility did not provide a policy related to nursing schedules.1. Review of the Monthly Work Schedule, dated August 2025, showed no RN scheduled to work.Review of the Monthly Work Schedule, dated September 2025, showed no RN scheduled to work.Review of the facility provided time sheets showed no RN clocked in or out on 09/13/25, 09/20/25, 09/21/25, and 09/28/25. Review of the facility provided time sheets showed on 09/14/25 an RN clocked in at 7:00 A.M. and clocked out at 11:00 A.M. (4 hours).Review the facility provided time sheets showed on 09/27/25 the Director of Nursing (DON) clocked in at 10:00 A.M., clocked out at 2:00 P.M., and clocked in at 4:00 P.M. and clocked out at 8:00 P.M. (8 non-consecutive hours).During an interview on 10/02/25, at 12:45 P.M., Licensed Practical Nurse (LPN) D said he/she worked a rotating scheduled and there was not an RN that worked…

    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 · Ecited before2025-12-12 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #1, #2, #3, #4, #5, #6) . The facility census was 79.Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for six residents (Resident #1, #2, #3, #4, #5, and #6) . The facility census was 79. Review showed the facility did not provide a shower policy. 1. Review of the facility current Shower Schedules showed the following:-room [ROOM NUMBER] to 108 scheduled for Monday and Thursdays;-room [ROOM NUMBER] to 118 scheduled for Tuesday and Fridays;-room [ROOM NUMBER] to 118 make up days on Wednesday, Saturday, Sundays;-room [ROOM NUMBER] to 210 scheduled for Monday and Thursday;-room [ROOM NUMBER] to 218 scheduled for Tuesday 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 · Ecited before2025-12-12 · tag F0725 — failed to have enough nursing staff — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to have sufficient nursing staff to meet the needs of the residents. The facility failed to provide showers per the preferences of three residents (Residents #1, #2, and #3), answer call lights in a timely manner for one resident (Resident #4) who experienced a fall, and repositioning and meal assistance/cueing for one resident (Resident #6). A sample of 12 residents was reviewed for staffing. The facility census was 84. Review showed the facility did not provide a shower policy.1. Review of the resident's census, dated 01/22/26, showed a total of 84 residents with 22 residents on 100-hall. Review of a listing provided by the Administrator and Director of Nursing (DON), on 01/22/26, showed eight of the 22 residents on the 100-hall required two-person assist. Review of the facility's Daily Staffing Breakdown Sheets showed nursing staff scheduled on 100-hall as follows: -On 01/19/26, day shift had two nurses, one CMT, and one CNA;-On 01/19/26,…

    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 · D2025-01-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to three residents (Resident #1, #2, and #3) out of a sample of thirteen residents. The facility's census was 71. Review of the facility's policy titled Daily Care Needs, dated March 2015, showed the following: -The purpose of daily care needs is to refresh the resident and provide cleanliness, comfort, and neatness; -Before beginning care, staff should check the bathing schedule. Review of the facility's policy titled Bath (Shower), dated March 2015, showed the following: -It is the policy of the facility to provide a shower to maintain skin integrity, comfort, and cleanliness; -Staff should encourage the resident to do as much of his/her own care as possible; -Supervise and assist as necessary. 1. Review of Resident #1's face sheet (a document that gives a patient'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon record review and interviews, the facility failed to perform a complete admission assessment, including a skin assessment, and did not identify and provide timely treatment for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1). The facility census was 71. Review of a facility policy titled admission Nurse's Note, dated March 2015, showed the following: -The purpose of the policy is to ensure information is documented for the resident upon admission; -Upon admission of a resident, the nurse will document a body audit which includes site and size of the scars, rashes, bruises or abrasions, pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) or stasis ulcer (wound to the leg or ankle caused by abnormal or damaged veins), and general overall appearance and cleanliness. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 10/30/24; -Diagnoses included…

    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 · F2024-08-23 · 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 and interview, the facility failed to maintain ceiling vents to ensure condensation and/or peeling paint did not drop from the vent onto the food preparation area. This had the potential to affect all 65 residents of the facility who received their meals from the facility kitchen. 1. During the initial tour of the kitchen on 08/20/24, at 9:00 A.M., with the Dietary Manager (DM), three ceiling vents were observed to have rust, dust, and peeling paint on and around the vents. One vent, located in front of the freezer, was observed to be falling from the ceiling. Another vent, located above the edge of the food preparation table, had condensation dripping from the edges of the vent, landing in front of the food preparation table. The drips were confirmed by the DM and [NAME] #1. They both confirmed there was a potential for the condensation and/or peeling paint to fall into food being moved from the stove to the preparation table and vice versa. During an interview on 08/23/24, at 1:20 P.M., the Maintenance Director (MD) said that he was responsible for the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-23 · tag F0761 — failed to label and store drugs safely — pattern
    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, the facility failed to ensure insulin pens were dated when opened for seven of 13 residents (Residents #8, #53, #49, #33, #55, #34, and #11) who were administered insulin in the facility. The facility failed also failed to ensure five vials of influenza vaccines were not expired in two of two medication rooms. Review of an undated facility policy titled, Labeling Drugs and Medications, showed all drugs and biologicals must be properly labeled and legible at all times. Review of an undated facility policy titled, Medications, Storage of, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. Observation and interview on 08/21/24, at 1:36 P.M., of the Magnolia medication room with Licensed Practical Nurse (LPN) #6 showed two boxes containing vials of influenza vaccine that were noted to have an expiration date of 06/30/24. LPN #6 confirmed that the vials were expired and should…

    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 · E2024-08-23 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain food at a palatable temperature on one of three halls (300 hall) when six on the hall (Residents #17, #18, #21, #29, #33, and #38) complained of cold food on the hall of 27 residents. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following guidance: -Temperatures of hot foods should be maintained at no less than 140.0 degrees Fahrenheit (F) during meal service; -Hot food should be at least 120 degrees F when served to the resident. 1. Review of Resident #21's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 05/07/24, showed the resident was moderately cognitively impaired. During an interview on 08/20/24, at 11:41 A.M., the resident said most times the food is adequate, but it can be cold. He/she ate his/her meals in the dining room. 2. Review of Resident #18's quarterly MDS, with an ARD of 06/12/24, showed the resident was moderately cognitively impaired. During an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2024-08-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for one resident of one resident (Resident #216) reviewed for EBP, out of a total sample of 22, who had had a peripherally inserted central catheter (PICC line - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) and received antibiotics. Review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, showed the following: -The purpose of the policy is to prevent broader transmission of MDRO (multi-drug resistant organisms) and to help protect patients with chronic wounds and indwelling devices; -EBP (enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Review of the EBP-Enhanced Barrier Precautions in-service, dated April 2024, provided by the Administrator showed the following: -Staff will notice a new dot on the name tags by residents' doors; -EBP is indicated 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-23 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 Minimum Data Set (MDS - mandated federal assessment completed by facility staff) assessment was accurate and complete for one resident (Resident #24) of 22 residents whose MDS were reviewed. Review of the Resident Assessment Instrument manual, version 1.19.1, dated October 2023, showed the following: -The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status; -In addition, an accurate assessment required collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. 1. Review of Resident #24's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), showed the following:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to document and follow physician's orders related to blood sugar tests for one of one resident (Resident #23) reviewed for insulin use out of a total sample of 22. 1. Review of Resident #23's Face Sheet,' located in the 'Face Sheet tab of the EMR, showed the following: -admission date of 07/05/24; -Diagnoses included diabetes and bilateral (both sides) shoulder fractures. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 07/11/24, showed the following: -Cognitively intact for daily decision-making' -Administered insulin on six out seven days during the observation period. Review of the resident's Physician Orders, located under the Orders tab of the EMR, showed an order for the resident's blood sugar level to be checked before meals. Review of the resident's nursing Progress Notes, dated 08/01/24 at 12:46…

    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 before2024-08-23 · 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 record review and interview, the facility failed to ensure an environment as free of hazards of possible when staff failed to transfer one resident (Resident #38), of 22 sample residents, with two staff members as care planned when using the mechanical lift (Hoyer Lift). 1. Review of Resident #38's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 07/20/19; -Diagnoses included of type II diabetes mellitus with diabetic neuropathy (causes weakness, numbness and pain, usually in the hands and feet), cerebral infarction (stroke), and acquired absence of left leg below the knee (BKA). Review of the resident's comprehensive care plan, initiated 07/14/21, located under the RAI tab in the EMR, showed an identified problem as required assistance of 2+ people for mobility and transfers/Hoyer lift to wheelchair and toilet. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), with an assessment reference date (ARD) of 04/04/24, showed…

    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 · E2022-09-13 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #8, Resident #47 and Resident #104). The facility census was 60. Record review of the facility's policy titled Do Not Resuscitate (DNR- do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Guidelines, undated, showed the following: -The facility recognizes the right of any competent resident or person responsible for making health care decisions for the resident to request the cardiopulmonary resuscitation (CPR) be withheld in the event of cardiac or respiratory arrest; -Upon admission, the social services designee will provide information on CPR to the resident and/or resident's legal representative 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-13 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to obtain physician's orders for side rail use; and failed to include the side rail on the care plan for three residents (Resident #7, Resident #43, and Resident #50). Staff failed to complete ongoing assessments to ensure the side rails are appropriate for use, failed to include the side rail on the care plan for four residents, and failed to obtain physician's orders for the use of side rails for one resident (Resident #12). The facility's census was 60. Record review of the facility's policy titled Side Rail Protocol, undated, showed the following: -Before placing a side rail read the following process to ensure the appropriateness and safety for the resident; -Physician/Director of Nursing…

    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 · E2022-09-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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

    Based on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when off going and on coming nurses/certified medication technicians (CMTs) failed to count narcotics/controlled medications and failed to sign the controlled substance shift change record during shift change for two of two medication carts, two of two nurse treatment carts, and one of two refrigerator lock boxes located in the facility. The facility census was 60. Record review of the facility policy titled, Narcotic Count, undated, showed the following: -Purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies; -One registered nurse (RN), licensed practical nurse (LPN), or certified medication technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift.; -Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming…

    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 · E2022-09-13 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 below five percent when staff made three errors out of 27 opportunities, resulting in an error rate of 11.11 percent, affecting three residents (Resident #6, #24, and #37). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. Record review of the Novolog FlexPen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before…

    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 · E2022-09-13 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 observation, interview, and record review, the facility failed to ensure significant medication errors did not occur, when staff failed to properly administer insulin to two residents (Resident #6 and Resident #37) and failed to properly administer insulin and failed to administer an oral diabetes medication as ordered for multiple consecutive days to one resident (Resident #24). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-13 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to one resident (Resident #7) and failed to offer the pneumococcal vaccine to two residents (Resident #35 and Resident #36). The facility census was 60. Record review of the facility policy titled, Immunization Recommendations for Residents of Long-Term Care Facilities, undated, showed the following: -Timing of Immunizations: -Pneumococcal: PCV20 (PREVNAR 20) and PPSV23 (Pneumococcal Polysaccharide vaccine); -Pneumococcal vaccination in persons ages 65 and older years, unless contraindicated will be administered according to the following guidelines when determining the vaccination status; -Adults 19 and [AGE] years old with certain medical conditions or other risk factors (Medical Conditions or Risk Factors) who have not already received a pneumococcal conjugate vaccine should receive either: A single dose of PCV 15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23) or a single dose 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 staff utilized proper infection control practices, to promote healing and prevent infection, during wound care for one resident (Resident #14) with a Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon or muscle). The facility had a census of 60. Record review of the facility policy titled, Wound Care and Treatment, undated, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -Clean technique is used. Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -If the resident is soiled, wound care must not be done until he/she is cleaned; -There must be a specific order for the treatment; -Handwashing must be done as outlined in the guidance; -Cut the tape with clean scissors; -Put gloves on; -Remove the soiled dressing and place in the trash bag; -Remove the gloves and discard into the bag; -Clean scissors with 60 seconds of contact…

    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 · D2022-09-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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

    Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #24) had a complete order for a catheter (a sterile tube inserted into the bladder to drain urine) with the size of catheter/balloon bulb included. The facility census was 60. Record review showed the facility did not provide a policy regarding catheter orders. Record review of the facility's Charting and Documentation Policy, undated, showed the following for catheter care documentation should include: -Type of procedure performed and who performed it; -Date and time the procedure was performed; -Type of and size of catheter used. 1. Record review of Resident #24's face sheet (admission data) showed the following: -admission date of 3/21/21 with a latest return of 2/25/22; -Diagnoses included chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and type two diabetes mellitus (condition that occurs when the body cannot use glucose (type of sugar) normally) with diabetic nephropathy (kidney disease) and neuromuscular dysfunction of bladder…

    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 · E2019-10-18 · tag F0575 — pattern
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure required postings including resident rights, abuse/neglect hotline, and Ombudsman contact information, was posted in a prominent location for residents, visitors, and staff. The facility census was 76. 1. Observation on 10/15/19 at 12:45 P.M., showed the facility posted Resident Right information, Ombudsman contact information, and the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information in the kitchenette of the main lobby area, in the far right corner on a wall, facing away from the main entrance. The Resident Right poster consisted of fine print which may not be visible to all residents and visitors. The facility did not have the Resident Rights information, Ombudsman contact information, or the DHSS Abuse and Neglect Hotline information posted in any other resident accessible are During an interview on 10/18/19, at 11:52 A.M., the Administrator said the Resident Rights, State agency, and Ombudsman information was posted on a wall in the main lobby; it could be difficult 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-10-18 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to provide a switch in two common-use restrooms, located on the service hall, that would activate the resident call light system. This deficient practice had the potential to affect all residents and visitors who might need to use the toiletsand required staff assistance. The facility had a census of 76. 1. Observation on 10/15/19, beginning at 8:00 A.M., showed two unsecured common-use restroom doors, located in the service hall, in which residents could access. Both restrooms did not have an call light activation switch. During an interview on 10/15/19, at approximately 9:00 A.M., the maintenance supervisor said he did not know the restrooms in the service halls needed a call light activation switch.

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to JAMES & JUDY LINCOLN — 56 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 1 of 52.4-1.4 vs chain
The other 55 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Camdenton Windsor EstatesCamdenton, MO 1 of 5Crestview HomeBethany, MO 1 of 5Grand River Health CareChillicothe, MO 1 of 5Lebanon North Nursing & RehabLebanon, MO 1 of 5Lewis & Clark GardensSaint Charles, MO 1 of 5Maryville Rehabilitation & Health Care CenterMaryville, MO 1 of 5Pacific Care CenterPacific, MO 1 of 5Parkside ManorColumbia, MO 1 of 5Pin Oaks Living CenterMexico, MO 1 of 5River City Living CommunityJefferson City, MO 1 of 5Rocky Ridge ManorMansfield, MO 1 of 5South Hampton Rehabilitation & Health Care CenterColumbia, MO 1 of 5Springfield VillaSpringfield, MO 1 of 5Strafford Rehabilitation & Health Care CenterStrafford, MO 1 of 5Troy ManorTroy, MO 1 of 5Villa At Blue Ridge, TheColumbia, MO 1 of 5Warrenton ManorWright City, MO 1 of 5Woodland Hills Healthcare And RehabilitationJacksonville, AR 2 of 5Brookhaven Nursing & RehabSpringfield, MO 2 of 5Carroll HouseCarrollton, MO 2 of 5Current River Rehabilitation & Health Care CenterDoniphan, MO 2 of 5Eldon Nursing & RehabEldon, MO 2 of 5Forsyth Rehabilitation & Health Care CenterForsyth, MO 2 of 5Fulton Nursing & RehabFulton, MO 2 of 5Grandview Healthcare CenterWashington, MO 2 of 5Lebanon South Nursing & RehabLebanon, MO 2 of 5Point Lookout Nursing & RehabHollister, MO 2 of 5Shepherd Of The Hills Living CenterBranson, MO 2 of 5Sunset HomeMaysville, MO 2 of 5Willard Care CenterWillard, MO 2 of 5Windsor Rehabilitation & Health Care CenterWindsor, MO 3 of 5Claru Deville Nursing CenterFredericktown, MO 3 of 5Glasgow GardensGlasgow, MO 3 of 5Glendale Gardens Nursing & RehabSpringfield, MO 3 of 5Hartville Care CenterHartville, MO 3 of 5Hermitage Nursing & RehabHermitage, MO 3 of 5Maries ManorVienna, MO 3 of 5St James Living CenterSaint James, MO 4 of 5Clearview Nursing CenterSikeston, MO 4 of 5Crowley Ridge Care CenterDexter, MO

Showing 40 of 55; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
LINCOLN, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/31/2015
LINCOLN, JUDYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL50%since 07/31/2015
ROGERS, KATHLEENIndividualW-2 MANAGING EMPLOYEEsince 07/13/2015
LTC MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/31/2015

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.1M
Net patient revenuemost recent cost report
-21.7%
Operating marginrevenue minus expenses
$2.0M
Related-party expense32% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 7%Other / private 32%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 32% 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

$273per resident / day
operating cost
$8,313per month
≈ monthly operating cost
$225per 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 265853. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-23, 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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