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Bishop Spencer Place, Inc, The

4301 Madison Avenue, Kansas City, MO 64111 · Non profit - Corporation · 57 certified beds · (816) 931-4277 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Jan 2026Resident-funds citation (F0569)1 immediate-jeopardy citation$8,021 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • 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
  • it has a citation for mishandling residents’ money or property (F0569)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,021 in federal fines (most recent 2024-07-29)

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.

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Sononet<0.1 mi
901 W 43rd St · (816) 569-2200 · Call to confirm hours
Pharmacy
4240 Southwest Trfy · (816) 839-6547 · Call to confirm hours
Grocery
4025 Mill St · (816) 561-2280 · Call to confirm hours
Park
On Broadway at Westport Northbound Farside · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 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 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.3%18.1%15.4%better
Long-stay residents who lose too much weight6.9%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%1.1%0.9%typical
Long-stay residents with a urinary tract infection7.8%2.3%2.0%worse
Long-stay residents with depressive symptoms13.9%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 injury0.0%4.1%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication3.2%25.6%18.9%better
Long-stay residents given the seasonal flu vaccine85.2%90.9%95.3%worse
Long-stay residents with pressure ulcers11.2%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control13.2%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.5%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine67.6%63.5%79.4%worse
Short-stay residents rehospitalized after admission27.1%26.0%22.6%worse
Short-stay residents with an outpatient ER visit10.1%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days0.682.111.67better
Long-stay outpatient ER visits per 1,000 resident days1.262.331.80better

* 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.

56.8% 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 228 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.8%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
57.9%U.S. median 56.6%
Met the expected recovery
0.77U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 57.9% 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 95 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 0.77 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.8%CMS range 49.9–62.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.8–14.410.7%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 discharge57.9%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 discharge35.8%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 discharge66.3%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 identified96.9%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 setting75.8%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 discharge90.1%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 stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%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 hospitalization5.7%CMS range 3.6–8.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.84
RN hours/ resident / day
1.65
LPN hours/ resident / day
2.97
Aide hours/ resident / day
5.46
Total nurse hours/ resident / day
0.37
RN hoursweekends
40.6%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 57 beds and averages 47.3 residents a day — about 83% occupied, or roughly 10 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 5.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 is at or above 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 4.41 hrs/resident/day on weekends vs 5.88 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.03 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-09)
9
at the previous standard inspection (2024-02-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Immediate jeopardy · J2024-07-29 · tag F0760 — failed to prevent significant medication errors — isolated
    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 interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free from a significant medication error. On 7/12/24 Resident #1 was administered 5 milliliters (ml) (100 mg (milligrams)/5 ml) oral solution of morphine concentrate (a opiate medicine used to treat moderate to severe pain) instead of the physician ordered 0.5 ml (10 mg) by mouth PRN (as needed) every 6 hours for pain. Narcan (a medicine that can save someone from a prescription Opioid medicine overdose) was ordered by the physician due to the dosage being 10 times the amount ordered and administered. The facility census was 48 residents. The Administrator was notified on 7/24/24 at 2:12 P.M., of an Immediate Jeopardy (IJ) which began on 7/12/24. The IJ was removed on 7/24/24 as confirmed by surveyor onsite verification. Review of the facility's Medication Administration policy, dated 6/29/2023, showed: -Purpose was to administer medications at approximate times as an individual would in their home…

    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 · Fcited before2026-01-09 · tag F0880 — failed to prevent and control infections — widespread
    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, interviews, and record review, the facility failed to maintain an appropriate infection control program to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and others; and failed to ensure appropriate infection control practices were maintained during one sampled resident's (Resident #21) wound care treatment out of 14 sampled residents. The facility census was 53 residents. Review of the facility's policy titled [NAME] Place Infection Prevention Plan dated 9/10/25 showed:-The Director of Nursing (DON) in collaboration with the Infection Prevention nurse had the authority to institute any surveillance, prevention, or control measures or study when there was reason to believe that any resident, personnel, or visitor may be in danger.-This authority and responsibility included, but was not limited to:--Developing and implementing a preventative and corrective program 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-09 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    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 an antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) program was in place which had the potential to affect all residents in the facility. The facility census was 53 residents. Review of the facility's policy titled Antimicrobial Stewardship in Senior Living Communities, GA-457 dated 9/23/25 showed:-The facility would establish and maintain as Antimicrobial Stewardship Program (ASP) to ensure optimal use of antimicrobials in the treatment and prevention of infectious diseases.-The ASP would focus its efforts on reviewing appropriateness of antimicrobial regimens for residents within the facility.-All residents with antimicrobials would be screened/reviewed by the Pharmacist.-Residents whom staff deemed high-level targets would get a formal review and, when appropriate, a recommendation would be made to the clinical staff regarding suggested changes in therapy.-ASP recommendations would be communicated to providers responsible 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 · E2026-01-09 · 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 ensure their facility Criminal Background Investigations policy showed a check of the Nurse Aide (NA) Registry would be completed for all potential facility employees and volunteers; subsequently, three facility employee records (Employees C, D, and E) out of five facility employee records sampled did not have NA Registry background screenings completed prior to hire, potentially affecting any resident at the facility. The facility census was 53 residents.Review of the facility's Criminal Background Investigations, HR-008 policy, revised 2/28/22, showed:-Applicants will complete the Post-Offer Credit Report Act (FCRA) Disclosure and confirm their understanding of the criminal background check requirement. Applicants who do not agree to a post-offer background check will not be allowed to move further in the on-line application process.-A post-offer background check will review any history of felony convictions in the past seven years or pending criminal charges when the third-party vendor e-consent form is completed.-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 · E2026-01-09 · 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 interview and record review, the facility failed to ensure comprehensive care plans were up to date and reflected three sampled residents (Resident #50, #57, and #73) current status out of 14 sampled residents. The facility census was 53 residents.Review of the facility's policy titled Bishop [NAME] Place (BSP) Service/Care Plans dated 10/6/25 showed:-The purpose of the policy was to identify the components of a resident's service/care plan and provide guidance on how the service/care plan should be created and implemented for the resident's daily care routine.-Service/Care plans should incorporate measurable goals, objectives and timetables that lead to the resident's highest obtainable level of independence.-Service/Care plans should be used in developing the resident's daily care routines and would be available to staff personnel who have responsibility for providing care or services to the resident.-The Interdisciplinary Team (IDT) was responsible for the development of an individualized,…

    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 · D2026-01-09 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 accurately document the residents [NAME] Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) for a resident on hospice services by not marking section J item number J1400 for prognosis less than six months to live for one sampled resident (Resident #54) out of 14 sampled residents the facility census was 53 residents.Review of the facility policy titled [NAME] Place (BSP) Minimum Data Set revised 12/2/25 showed:-A Registered Nurse (RN), also known as the MDS Coordinator, would be responsible for conducting and coordinating the development, completion, and submission of the MDS Assessment for each resident.-The individual who completed a portion of the MDS must have certified the accuracy of that portion of the assessment. -The MDS Coordinator or designee would be responsible for ensuring that a resident assessment was submitted to Federal and state MDS database in accordance with current federal 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR a requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #57) was reviewed for accuracy and updated after admission to the facility out of 14 sampled residents. The facility census was 53 residents.A policy related to PASRRs was requested and not received prior to exit on 1/9/26.1. Review of Resident #57's PASRR Level One Screening dated 9/1/21 showed:-The screening had been completed by a local hospital prior to the resident's admission to the facility.-The resident did not show any signs or symptoms of a major mental disorder.-The resident had never been diagnosed with a major mental disorder. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/24/25 showed:-The resident felt down, depressed, or hopeless two to six…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · 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 one sampled resident's (Resident #21) wound care orders were followed during observation of his/her wound care out of 14 sampled residents. The facility census was 53 residents.A policy related to following physician orders was requested and not received prior to exit on 1/9/26.1. Review of Resident #21's admission Record showed the resident readmitted to the facility on [DATE] with a diagnosis of Osteomyelitis (an infection and inflammation of bone tissue).Review of the resident's Order Summary Report dated January 2026 showed:-The resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) Pressure Ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to his/her coccyx (the small bone at the bottom of the spine).-Staff were to cleanse with normal…

    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 · D2026-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 one sampled resident (Resident #58) out of 14 sampled residents had bed assist devices installed in a timely manner, clarified if the resident needed a right side bed assist bar or bilateral bed devices, and failed to ensure the resident's care plan identified specifically the equipment needed to improve the resident's independence with bed mobility and transfers. The facility census was 53 residents.Review of the facility's Bed Rails Policy, revised 12/24/25 showed:-Bed rails will also refer to grab bars, halo bars, assist bars, and safety rails (adjustable metal or rigid plastic bars that attach to a bed). Transfer bars, mobility enhancers, and bed canes are rails used on beds and are intended to 1) reduce the risk of falling from bed, 2) assist the resident in repositioning in bed, and/or 3) assist the resident in transitioning into or out of the bed.-The Interdisciplinary Team will use data collected from individual bed rail…

    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 · D2026-01-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide catheter care, document catheter care, or refusal of catheter care for one sampled resident (Resident #33) out of 14 sampled residents. The facility census was 53 residents. Review of facility policy titled Management of Foley Catheters revised 12/2/2025 showed:-Document the care in the electronic medical record. 1. Review of Resident #33's Admissions Record showed the resident's readmission date of 11/11/25 with the following diagnoses:-Urinary tract infection.-End stage renal disease (ESRD is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant). Review of the resident's Treatment Administration Record (TAR) dated November 2025 showed 13 out of 38 opportunities where catheter care was not documented.Review of the resident's progress notes dated November 2025 showed no documentation where catheter care was refused by the resident. Review of the resident's Order Summary Report dated November…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-29 · 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 ensure two sampled residents (Resident #2 and #3) were free from medication errors, out of 10 sampled residents. On 3/25/24 Resident #2 was given the wrong medication when the Certified Medication Technician (CMT) handed the medication to Licensed Practical Nurse (LPN) A, who then administered the medication to the wrong resident, and on 4/4/24 Resident #3 was given his/her medication twice. A family member had given the medication to the resident and it was not signed out on the Medication Administration Record (MAR). When the resident returned to the facility the medication was given to the resident for the second time. The facility census was 48 residents. Review of the facility's Medication Administration policy, dated 6/29/2023, showed: -Purpose was to administer medications at approximate times as an individual would in their home environment while continuing to comply with physician orders. -The policy was to assure that prescribed medications…

    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
Show the remaining 14 citations
  • Potential for harm · F2024-02-06 · 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 keep the walk-in freezer floors clean; to retain operable thermometers in all freezers to confirm adequate temperature ranges; to maintain sanitary food preparation equipment; to change the deep fryer oil in a timely manner; and to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination), in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 53 residents with a licensed capacity for 57 residents at the time of the survey. 1. Observation on 1/31/24 between 9:07 A.M. and 11:30 A.M. during the initial kitchen inspection showed the following: -There were plastic strips, a bread clip, and a pen under the racks in the walk-in freezer. -The walk-in freezer had no thermometer inside. -The oil in the deep fryer was so dark the bottom basket resting rack was not visible. -The manual can opener had an unknown residue on its…

    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 · E2024-02-06 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 disperse remaining resident trust account funds and to convey within 30 days of death, a final accounting of the resident trust fund account to the individual or probate jurisdiction administering the resident's estate in accordance with state law after the residents expired for three sampled residents (Residents #106, #107, and #108) out of three expired residents sampled for disbursement of funds. The facility census was 53 residents. Review of the facility's policy titled Management of Residents' Funds dated 2024 showed: -A representative of the business office would review the resident's records upon notification of a resident's death. -If the resident had any funds being held by the facility, the funds should be transferred to the resident's representative, the state or probate jurisdiction administering the resident's estate. Review of the Personal Funds Account Balance Report form dated [DATE] showed: -Nursing facilities were required to submit…

    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 before2024-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's oxygen tubing was stored in a bag and dated when staff had changed out the tubing for two sampled residents, (Resident #8 and Resident #304), and to ensure a resident's Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while sleeping) machine had distilled water for the reservoir, and to ensure the resident's CPAP mask was cleaned daily for one sampled resident (Resident #305) and the CPAP mask was stored appropriately in a bag when not in use for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Policy Oxygen Therapy for Adults in Long Term Care Setting, dated 8/4/22 showed: -Oxygen therapy medically prescribed for residents would have been administered according to health and safety guidelines and delivered either by Oxygen mask, nasal cannula, or nasal catheter. -A nasal cannula…

    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 · E2024-02-06 · 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 three of the four medication carts were locked when the nursing staff was not within direct line of sight of the medication cart. The facility census was 53 residents. Review of the facility's policy, Storage of Medications, dated as retrieved on 2/6/24 showed: -The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing drugs and biologicals (a therapeutic substance, such as a vaccine or drug) should have been locked when not in use. -Carts used to transport such items should not have been left unattended if open or otherwise potentially available to others. 1. Observation on 1/31/24 at 11:25 A.M. with Registered Nurse (RN)/Wound Care Nurse (WCN) showed: -He/She went into a resident's room to do wound care. -He/She left the treatment cart in the hallway unlocked, while he/she was in the room for 20 minutes. -Two residents passed within two feet of the unlocked treatment cart while the nurse was 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-06 · 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 properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for one sampled resident (Resident #47) out of five residents sampled for TB screening. The facility also failed to implement infection control practices by not following infection control protocols during wound care for one sampled resident (Resident #355); to ensure the Foley catheter (a tube passed into the bladder to drain urine) tubing was not touching the floor and the drainage bag was properly placed in a clean dignity/privacy bag (a bag to place a Foley catheter drainage bag into to keep out of view) for one sampled resident (Resident #30); and to follow the standard of practice for wound care and infection control practice for one sampled resident (Resident #2) out of 15 sampled residents. The facility census was 53…

    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 · D2024-02-06 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain a complete Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level I Screening for one sampled resident (Resident #12) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's Behavior Assessment and Monitoring Policy dated 3/13/23 showed: -The interdisciplinary team will utilize information from the PASRR process as well as complete a comprehensive assessment of the resident needs, strengths, goals, life history and preference using the Resident Assessment Instrument (RAI) process specified by Centers for Medicare and Medicaid Services (CMS). -The Preadmission and PASRR Process: identifying potential mood and behavioral changes, support and care plan interventions is part of the assessment process as well as coordination of care. It is the policy of the facility to screen all potential admissions on an individualized basis for behavioral health needs. -Social…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a pain patch was not left on the resident's breakfast tray for one sampled resident (Resident #105) and to ensure a nursing staff member did not leave medications in the resident's room for the resident to self-administer without a nursing staff member present for one sampled resident (Resident #19) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy titled Self-Administration of Medication dated as revised 3/8/21 showed instructions to assess residents to determine if they were capable of self-administering over-the-counter medications. 1. Review of Resident #105's care plan dated 1/24/24 showed the resident experienced pain. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/30/24 showed the following staff assessment of the resident: -Cognitively intact. -Experienced occasional pain with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · 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 a physician ordered special mattress was in place to minimize a Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) for one sampled resident (Resident #2) out of 15 sampled residents. The facility census was 53 residents. Review of the facility's policy, Skin Care - Wound Care), dated 2/6/24 showed: -The Wound Care Team and/or the primary nurses were responsible for providing care for the patient with a skin wound. -Ordered or recommended wound care would have been provided by facility staff while properly following all standards of practice for wound care. -Staff was to have implemented Individualized Plan of Care. -Staff was to have implemented measures to manage tissue load to minimize pressure, friction and shear. -Staff was to have provided ordered 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 · D2024-02-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    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 complete the Pneumococcal Immunization Informed Consent form correctly before having the resident and nurse sign it; and failed to re-offer the immunization for one sampled resident (Resident #8) out of five residents sampled for immunizations. The facility census was 53 residents. Requested a policy for Pneumococcal Immunization and received an updated Consent for Vaccine form. 1. Review of Resident #8's face sheet showed he/she was admitted on [DATE] and re-admitted on [DATE] with the following diagnoses: -Chronic (persisting for a long time or constantly recurring) Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing) with acute (sudden onset) lower respiratory infection. -Chronic Respiratory Failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide). -Dependence on supplemental oxygen. Review of the resident's Pneumococcal Immunization…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    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 arrange for a safe and orderly discharge for one sampled resident (Resident #2) when he/she was discharged to a lodging facility after the resident and family members voiced concerns about his/her transfer and outside services were not in place at the time of discharge out of seven sampled residents. The facility census was 46 residents. Review of the facility Discharge Summary and Plan dated 11/20/16 showed: -Policy Statement: -It is the policy of this facility that residents who have a planned discharge from the facility have a completed discharge plan and recapitulation of stay completed to facilitate continuity of care after discharge. -Post-discharge continuity of care is well known to improve health outcomes for discharged residents and to help prevent readmissions to the hospital. -Over view of components of the policy from the regulations: --A post-discharge plan of care that is developed with the participation of the resident and, with the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-19 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents receiving dialysis (a treatment for kidney failure that removes waste and excess fluids) had physician's orders indicating where and when the resident was to go for dialysis appointments and to ensure ongoing communication between the facility and dialysis centers was maintained to provide continuum of care and to develop individualized comprehensive care plans that included the resident's dialysis goals and interventions for two sampled residents (Resident #21 and Resident #41) out of 12 sampled residents. The facility census was 44 residents. Record review of the facility Caring for a Dialysis Resident policy dated 5/20/21 showed: -The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. -Coordination of care includes: --Times of dialysis therapy and dialysis access orders. --Dialysis clinic appointment 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 · E2022-07-19 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary and hygienic practices before, during and after food preparation tasks. These practices potentially affect an unknown number of residents who received their meals from the facility's kitchen. The facility census was 44 residents. 1. Observations on 7/15/22 between 5:03 A.M. and 7:29 A.M. in the kitchen, showed: -The Executive Chef (EC) walking around the various food preparation tables with a digital thermometer testing and taking food temperatures. -The EC had a surgical, infection control mask covering his/her mouth and nose. -The EC had facial hair protruding out from the sides of his/her surgical mask, resembling that of a beard. -The EC did not have his/her facial hair covered with a hair restraint. -In the refrigerated walk-in, there was a gallon container of Catalina French Dressing with its contents dripping over and on the outside of the container. -In the refrigerated walk-in unit there were several different types 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-19 · 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 ensure that foods were prepared in accordance with the current Food and Drug Administration (FDA) standards in order to preserve their nutrients. This practice potentially affects all residents and staff who eat foods from the kitchen. The facility census was 44 residents. 1. Observations on 7/15/22 between 5:03 A.M. and 7:29 A.M. in the kitchen, showed: -At 5:45 A.M. the Sousse Chef (SC) placed a tray of pork breakfast sausage links into the oven. -The oven was set at a temperature of 350ºF (degrees Fahrenheit - unit of measurement as a temperature scale). -At 6:10 A.M. the SC removed the tray of pork sausage links from the oven and took the temperatures. -The temperature of the pork sausage links read in excess of 200ºF. -The SC stopped taking the temperature of the sausage links when the temperatures reading were reading over 200ºF. During an interview on 7/15/22 at 6:13 A.M., the SC said: -The sausage links were of pork and fully cooked in their frozen state. -Pork meats were supposed to be cooked between…

    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 · Dcited before2022-07-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen nasal cannula (is the oxygen delivery tube with two small prongs that fit in the nostrils a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) tubing was stored per facility policy when not in use for one sampled resident (Resident #33) out of 12 sampled residents. The facility census was 44 residents. Record Review of Oxygen Therapy for Adults in Long Term Care Setting policy dated 11/2/19 revised 9/21/21 showed: - All nasal cannulas, oxygen tubing, and nebulizer masks are to be stored in a plastic bag when not being used. -All nasal cannulas and oxygen tubing is to be prevented from dragging or touching the floor by use of a plastic bag to store tubing. 1. Record review of Resident #33's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Dependence on supplemental Oxygen (occurs when there is not enough…

    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

“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

$8,021 in federal fines across 1 penalty.

  • $8,021 — penalty dated 2024-07-29

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

Who owns this facility

Owner / managerTypeRoleSince
ACHELPHOL, RICHARDIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
CALVIN, KARENIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
COULTER, JAMESIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
ELVING, BEVERLYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
HAVENHILL, LISAIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/19/2019
HUTCHERSON, ANNEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
JOHNSON, JANIIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/15/2020
JOHNSTON, NANETTEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
KEYSE, ANDREWIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
LAMPO, JANEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
MCBRIDE, SYDNEYIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/07/2025
MEAUX, AMYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 05/03/2025
PURCELL, JASONIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
WOOTTON, KRISTENIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
SAINT LUKES HEALTH SYSTEM INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/27/2025
JACKSON, ANTHONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
SPARKS, RANDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2025

CMS files one row per role, so the 36 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$13.3M
Net patient revenuemost recent cost report
-39.2%
Operating marginrevenue minus expenses
$597K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 18%Medicare 21%Other / private 62%

This home reported $597K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$1,018per resident / day
operating cost
$30,944per month
≈ monthly operating cost
$731per 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 265768. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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