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Westgate

3130 John Duffy Dr, Joplin, MO 64804 · For profit - Individual · 120 certified beds · (417) 553-3688 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Jan 20261 immediate-jeopardy citation$70,134 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $70,134 in federal fines (most recent 2026-06-04)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 23% 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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
444 Four States Dr Ste 1A · (877) 783-4441 · Call to confirm hours
Pharmacy
1605 K66 · (620) 783-1636 · Call to confirm hours
Grocery
1842 W 21st St · (417) 622-8549 · Call to confirm hours
Park
4300 W 29th St · (417) 625-4750 · Typically dawn to dusk
Place of worship
3035 S Central City Rd · (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 2 of 5
Long-stay residentspeople who live here 2 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased18.4%18.1%15.4%worse
Long-stay residents who lose too much weight7.9%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.4%1.1%0.9%worse
Long-stay residents with a urinary tract infection4.4%2.3%2.0%worse
Long-stay residents with depressive symptoms10.1%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 injury7.5%4.1%3.3%worse
Long-stay residents whose ability to walk worsened20.0%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication43.1%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine99.1%90.9%95.3%typical
Long-stay residents with pressure ulcers3.9%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control15.5%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.9%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication3.3%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine60.0%63.5%79.4%worse
Short-stay residents rehospitalized after admission20.5%26.0%22.6%typical
Short-stay residents with an outpatient ER visit16.0%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.222.111.67worse
Long-stay outpatient ER visits per 1,000 resident days2.972.331.80worse

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.

35.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 71 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

35.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
59.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 59.0% 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 39 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% 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 some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF35.1%CMS range 24.6–45.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.2–14.610.7%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 discharge59.0%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 discharge66.7%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 discharge43.6%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 identified66.1%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 setting64.0%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 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 stay1.7%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 worsened1.7%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 hospitalization11.6%CMS range 7.3–16.67.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.481.02Oct 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

0.51
RN hours/ resident / day
0.82
LPN hours/ resident / day
2.41
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.27
RN hoursweekends
54.2%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 105.2 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 3.17 hrs/resident/day on weekends vs 3.97 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.60 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as 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

3
deficiencies at the latest standard inspection (2024-06-07)
12
at the previous standard inspection (2022-07-21)

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2026-06-04 · 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 provide care to promote the prevention and healing of pressure ulcers when staff failed to assess, monitor, document, and notify the physician for at least 17 days of a newly acquired Stage 4 (full thickness tissue loss with exposed bone) pressure ulcer that developed on one resident's (Resident #1) sacrum (the triangular bone located above the tailbone) which resulted in the resident requiring prolonged antibiotic treatment for probable osteomyelitis (an infection and inflammation of the bone typically caused by bacteria or fungi) and when staff failed to complete a wound treatment per physician order, and timely assess, document and notify the physician of five newly acquired pressure ulcers for one resident (Resident #2) in a selected sample of 10 residents. The facility's census was 100 residents.The Administrator was notified on 06/03/26, at 7:23 P.M., of an Immediate Jeopardy (IJ) which began on 05/05/26. The IJ was removed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Actual harm · G2023-09-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents received adequate supervision to prevent possible accidents when staff failed to respond to an alarm when one resident (Resident #1) left the facility at night, was found by a neighboring facility's staff, and suffered a fall with injury, and when the facility staff failed to have a process in place, and ensure all staff were trained on the process, to routinely check wander prevention devices to ensure they worked correctly for two residents (Resident #1 and Resident #2). The facility had a census of 101. Review of a facility policy titled, Wandering and Elopements, revised March 2019, showed the following information: -The facility is to identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -Residents identified as at risk for wandering, elopement, or other safety issues will have strategies and interventions to maintain the residents safety…

    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 before2026-06-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of skin breakdown when staff failed to timely and accurately assess and document related to Moisture Associated Skin Damage (MASD-inflammation and skin erosion caused by prolonged exposure to bodily fluids such as urine and feces) for one resident (Resident #3) in a selected sample of 10 residents. The facility's census was 100 residents. Review of the facility's Wound and Skin Care Protocol, revised November 2024, showed the following information:-Purpose to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. This protocol serves as a tool for treatment options for the staff member to utilize;-The Director of Nursing (DON) at each facility is responsible for informing and educating the attending physicians and the facility's Medical Director regarding facility wound care protocols. It will…

    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 plan of correction
  • Potential for harm · D2026-01-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed the resident's face. The facility census was 109.Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed Resident #1's face. The facility census was 109. On 01/08/26, facility management became of the noncompliance that occurred on 01/08/26. The facility reported the allegation, began an investigation, took steps to protect the residents, and began facility-wide in-service regarding abuse, neglect, dignity, and respect; began monitoring the resident for any psychosocial changes; and began monitoring the resident's skin for any new bruising, redness, or other concerns. The facility put plans in place to provide training on behavior interventions for the next three months and added the noncompliance to their Quality…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-07-01 · 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

    Based on record review, observation, and interview the facility failed ensure all residents were treated with dignity and respect when one staff (Licensed Practical Nurse D) grabbed one resident's arm (Resident #1) and grabbed food out of the resident's hand. The facility's census was 109.Review of the facility's policy titled Dignity, revised February 2021, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem;-Residents are treated with dignity and respect at all times;-Demeaning practices and standards of care that compromise dignity are prohibited;-Staff are expected to promote dignity and assist residents;-Staff are expected to treat cognitively impaired residents with dignity and sensitivity, addressing underlying motives or root causes for a behavior.1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 04/16/25;-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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system of record keeping to ensure all controlled substances (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) were accurately accounted for when staff did not accurately document all administrations of and could not easily reconcile the balance of a controlled medication for one resident (Resident #1) out of four sampled residents. The facility census was 110. The facility Administrator and the Assistant Director of Nursing (ADON) were notified of the Past Non-Compliance which occurred on 11/28/24. The facility staff began an investigation on 12/12/24 when the medication reconciliation error was found. The facility began immediate in-servicing of all staff who were on-site and as they arrived for work prior to beginning their shift. The facility also…

    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 · Past Non-Compliance
  • Potential for harm · E2024-06-07 · 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, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the the bathrooms of six residents (Resident's #51, #89, #32, #36, #39 and #102). The facility census was 108. Review showed the facility did not provide a policy that related to cleaning and maintain the bathrooms in residents' rooms. Review of the facility's cleaning sheet titled, Housekeeping 3 (300 hall), undated, showed the following: -Five step procedure for rooms included pull trash/sanitize can/replace liner, horizontal surfaces, vertical surfaces, dust mop, and damp mop; -Seven step procedure for bathrooms included check/refill supplies, pull trash/sanitize can/replace liner, dust mop/sweep, clean sink area/tub, clean commode/base, clean walls/partitions, and damp mop; -At 8:15 A.M., begin regular day cleaning on resident rooms 301, 303, 305, and 307 using five step/seven step procedure; -At 10:00 A.M., continue regular day…

    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 · E2024-06-07 · 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 all medications were stored per standards of practice when staff walked away and out of view of an unlocked medication cart containing resident medications. The facility census was 108. Review of the facility policy titled Administering Medications, revised 12/12, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse 1. Observation on 06/05/24, beginning at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medications for multiple residents and placed the cups containing the medication in the top drawer of the medication cart. The CMT then walked away from the medication cart without locking the care. The CMT walked to dining room approximately twenty-five feet away and turned his/her back to medication cart to check a blood pressure of a resident. The CMT was in not in line of sight of the unlocked medication cart. During an interview on 06/06/24, at 9:00 A.M., CMT E said he/she always locks 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 before2024-06-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all medical records were maintained in a confidential fashion when staff left the computer on medication cart unlocked, unattended, and visible to other for one resident (Resident #5). The facility census was 108. 1. Review of Resident # 5's face sheet showed the following information: -admission date of 05/06/24; -Diagnosis included hypertension (high blood pressure), diabetes, and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the resident had moderate cognitive impairment. Observations on 06/05/24, starting at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medication for the resident. CMT D then walked away from the medication cart with the computer screen showing patient information, including medication orders. CMT D walked to dining room approximately twenty-five feet away and turned his/her back to medication cart to check the resident's blood…

    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 · D2024-03-15 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to share a room with his or her roommate of choice and the right to receive written notice of the room change, including the reason, were protected when staff moved one resident (Resident #1) to a room on a different hall without a written notice issued or documentation of the resident's consent to the change. The facility had a census of 105. Review of the facility's policy titled, Room Change/Roommate Assignment, revised March 2021, showed the following information: -Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered; -Room changes initiated by the facility are limited to moves within the same building in which the resident currently resides, unless the resident voluntarily agrees to move to another building within the same facility; -Residents have the right to share a room with their roommate of choice, including a…

    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 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with standards of practice when staff failed to document a fall or complete post fall monitoring for one resident (Resident #3's) who suffered fall, resulting in a possible delay of identification of injury of a hip fracture. The facility census was 101. Review of a facility policy titled, Accidents and Incidents-Investigating and Reporting, revised July 2017, showed the following: -All accidents and incidents involving residents are to be investigated and reported to the Administrator; -The nurse supervisor, charge nurse, department director, or supervisor shall promptly initiate and document investigation of the accident or incident; -The incident will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities. 1. Review of Resident #3's face sheet (basic information sheet) showed the following information: -admission date 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-21 · 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 interview and record review, the facility failed to provided showers as preferred for nine residents (Resident #5, #13, #16, #39, #41, #68, #69, #74, and #78). The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. 1. During the resident group meeting held on 7/18/22, at 1:55 P.M., showed the following: -There were eight residents who attended the meeting; -The residents all agreed that they did not receive showers/baths on a regular basis and did not get two showers a week; -Resident #74 said he/she went three weeks without a shower and was finally given one last Wednesday or Thursday. He/she would really like to have a bath at least two times a week; -Resident #13 said he/she finally received a shower on Saturday but it had been nine days since his/her last shower and he/she would like to have a shower two times a…

    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 11 citations
  • Potential for harm · E2022-07-21 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete criminal background checks (CBC) or Family Care Safety Registry (FSCR) for two staff (Dietary Aide (DA) S and Licensed Practiced Nurse (LPN) R); failed to completed employee disqualification list (EDL) checks for four sampled staff (Registered Nurse (RN) Q, DA S, LPN R, and Housekeeper U); and failed to complete the Nurse Aide (NA) Registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) check for three sampled staff (DA S, LPN R, Housekeeper U), to ensure the staff did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility, out of ten sampled newly hired staff since last survey. The facility census was 89. Record review of the facility policy Payroll and Personnel, dated February 2022, showed the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-21 · 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, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes measurable objectives to meet the resident's medical and nursing needs identified in the comprehensive assessment for three residents (Residents #5, #50, and #78). The facility census was 89. Record review of a facility policy entitled Care Plan, Comprehensive Person-Centered, revised December 2016, showed the following information: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan will: -Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Describe services that would otherwise be furnished, but are not based on resident's refusal; -Include resident's stated goals upon admission; -Incorporate…

    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 · E2022-07-21 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to provide weekend activities that met the needs and interests of the residents in and out of the SCU (specialized care unit in long-term care facilities developed to provide specialized care for individuals living with dementia). Facility census was 89. Record review of the facility's policy for resident activities titled Group Programs and Activity Calendar, dated June 2018, showed the following: -Group activities are available in this facility and an activity calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available; -Both large and small group activities are part of the activity programs; -The activity calendar states all activities available for the entire month, which may also include scheduled in-room activities; -Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental and emotional needs; -Activities professionals plan scheduled activities for the month and post 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 · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-21 · 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, record review, and interview, the facility failed to document a pre-use assessment, obtain informed consent, and obtain a physician's order for the use of bed rails for five residents (Residents #22, #46, #50, #51 and #72). The facility failed to care plan the use of side rails for four residents (Residents #46, #50, #51, and #72) The facility census was 89. Record review of a facility policy entitled Proper Use of Side Rails, revised December 2016, showed the following information: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility; -Side rails are only permissible if they are used to treat a resident's condition and circumstances; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -The use of side rails as an assistive device will be addressed in the resident care plan; -Consent for side rail use will be obtained from the resident or legal representative, after presenting…

    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 · E2022-07-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces (dishes) were stacked wet instead of air dried, potentially causing bacteria growth and when staff failed to date or label stored food after opening. The facility census was 89. 1. Record review of the facility policy titled Dishwashing: Machine Operation, by Health Technologies, Inc. Guideline and Procedure Manual, 2016 Edition, showed the following information: -Use clean, washed hands to pull out clean racks, and allow to dishes to air dry before putting dishes away for storage; -The pots and pans will be drained and air dried on the drain counter. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may…

    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 · E2022-07-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to hand washing when providing personal hygiene care for two residents (Residents #51 and #72) and during a medication pass for five observed residents (Resident #5, #16, #41, #50, and #72). The facility census was 89. Record review of a facility policy entitled Handwashing/Hand Hygiene, revised August 2019, showed the following information: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub or soap and water before and after direct contact with residents; before preparing or handling medications; before donning sterile gloves; before handling clean or soiled dressings; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with objects in the immediate vicinity 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-21 · 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 — 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 to be adequately equipped with a full call light system when staff stored emergency call light pull cords where residents could not access the pull cord to call for staff assistance. The facility census was 89 residents. Record review of the facility's policy titled Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs; -Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident; -Ask the resident to return demonstration; -Explain to the resident that a call system is also located in his/her bathroom; -Be sure that the call light is plugged in and functioning at all times; -Report all defective call lights to the nurse supervisor promptly. 1. Observations on 7/19/22, beginning at 11:45 A.M., showed the following on the Special Care Unit (SCU); -room [ROOM NUMBER]'s bathroom, where two residents…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-21 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a hospital transfer for two residents (Resident #1 and Resident #50) out of 23 sampled residents. The facility census was 89. Record review of the facility policy Transfer or Discharge Notice, dated March 2021, showed the following information: -The resident and representative are notified in writing of the following information: -The specific reason for the discharge or transfer -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged ; -An explanation of the resident's rights to appeal the transfer or discharge to the state; -The facility bed-hold policy; -The names and contact information for the Office of the State of Long-term Care Ombudsman; -The reason for the transfer or discharge are documented in the resident's medical record. Record review of the facility form letter, titled Notice of 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-21 · 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 two residents (Resident #83 and #72) received showers/baths as needed to maintain good personal hygiene. The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. 1. Record review of the Resident #83's face sheet (gives basic profile information) showed the following information: -admission date of 6/10/22; -Diagnoses included malignant neoplasm (tumor) of brain, morbid (severe) obesity due to excess calories, muscle weakness, unsteadiness on feet, altered mental status, abnormality of gait and mobility, need for assistance for personal care, and cognitive communication deficit. Record review of the resident's Care Plan, dated 7/20/22, shows the following: -Requires assistance to complete daily activities of care safely related to weakness 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-21 · 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, observation, and record review, the facility failed to ensure appropriate safe medication administration, per standards of practice and facility policy, when staff left medication at the bedside of one resident (Resident #13). The facility had a census of 89. Record review of the facility policy, Administering Medications, dated April 2019, showed the following information: -Medications are administered in a safe and timely manner, and as prescribed; -Medication are administered in accordance with prescriber orders, including any required time frame; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer medication; -Residents may self-administer their own medication only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Record review of the website Missouri…

    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 before2022-07-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to ensure staff accurately documented colostomy care for one resident (Resident #50) and failed to remove a wound vac (suction pump, tubing and a dressing use to remove excess fluid and promote healing in wounds) orders and continued to document the wound vac, that was not in place, was changed twice per week for one resident (Resident #50). The facility had a census of 89. Record review showed the facility policy Colostomy/Ileostomy Care, dated October 2010, showed the following information: -The purpose of the procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Supplies needed, steps in the procedure; -Document in the resident's medical record the date, time, and individual who provided the care. Record review of website page Medline Plus, dated 11/2/2020, showed that the ostomy pouch (small, waterproof pouch used to…

    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

“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

$70,134 in federal fines across 1 penalty.

  • $70,134 — penalty dated 2026-06-04

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 CIRCLE B ENTERPRISES — 36 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 2 of 52.5-0.5 vs chain
Health inspection 2 of 53.1-1.1 vs chain
Staffing 3 of 52.0+1.0 vs chain
Quality measures 2 of 51.9+0.1 vs chain
The other 35 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Apple Ridge Care CenterWaverly, MO 1 of 5Autumn Oaks Caring CenterMountain Grove, MO 1 of 5Brent B Tinnin ManorEllington, MO 1 of 5Clinton Healthcare And Rehabilitation CenterClinton, MO 1 of 5Hill Crest ManorHamilton, MO 1 of 5Jefferson Health CareLees Summit, MO 1 of 5Lawson Manor & RehabLawson, MO 1 of 5Maywood Terrace Living CenterIndependence, MO 1 of 5Mountain View ManorPrescott, AZ 1 of 5Ridge Crest Nursing CenterWarrensburg, MO 1 of 5Truman Healthcare & Rehabilitation CenterLamar, MO 1 of 5Valley Manor And Rehabilitation CenterExcelsior Springs, MO 2 of 5Granby HouseGranby, MO 2 of 5Lakeview Health Care & Rehabilitation CenterBoonville, MO 2 of 5Quail Run Health Care CenterCameron, MO 2 of 5Riverdell Care CenterBoonville, MO 3 of 5Adair VillageClinton, MO 3 of 5Cotton Point Living CenterMatthews, MO 3 of 5Delhaven ManorSaint Louis, MO 3 of 5Desert Highlands Care CenterKingman, AZ 3 of 5Havasu Nursing CenterLake Havasu City, AZ 3 of 5Hunter Acres Caring CenterSikeston, MO 3 of 5Manor, ThePoplar Bluff, MO 3 of 5River Oaks Care CenterSteele, MO 3 of 5Sikeston Convalescent CenterSikeston, MO 4 of 5Communities Of Wildwood RanchJoplin, MO 4 of 5Heart Of The Ozarks Healthcare CenterAva, MO 4 of 5Heartland Care And Rehabilitation CenterCape Girardeau, MO 4 of 5Houston HouseHouston, MO 4 of 5Puxico Nursing And Rehabilitation CenterPuxico, MO 4 of 5Riverview Nursing CenterMokane, MO 4 of 5Riverways ManorVan Buren, MO 4 of 5Southgate Living CenterCaruthersville, MO 4 of 5Yuma Nursing CenterYuma, AZ 5 of 5Shady Oaks Healthcare CenterThayer, MO

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
CIRCLE B ENTERPRISES HOLDING COMPANY INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/10/2000
AGH1 LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/11/2025
SOVEREIGN HEALTHCARE GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/06/2025
BEAIRD, TODDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
BEDELL, DONALDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/10/2000
CALDWELL, MISTYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/10/2022
CASCONE, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/10/2019
BEDELL, BRYANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/12/2025
DCB REAL ESTATE PARTNERSHIP LPOrganizationADP OF THE SNFsince 04/01/2005
FG LLCOrganizationADP OF THE SNFsince 07/16/2019
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 08/16/2021
JOPLIN DEVELOPMENT PROPERTIES II LLCOrganizationADP OF THE SNFsince 06/01/2021
MID STATES INCOrganizationADP OF THE SNFsince 07/16/2019

CMS files one row per role, so the 18 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$9.0M
Net patient revenuemost recent cost report
+11.7%
Operating marginrevenue minus expenses
$1.8M
Related-party expense23% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 10%Other / private 21%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$223per resident / day
operating cost
$6,770per month
≈ monthly operating cost
$252per 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 265877. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-07, 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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