La Plata Nursing Home
100 Old Stagecoach Road, La Plata, MO 63549 · Government - County · 52 certified beds · (660) 332-4315 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.5% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.8% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 8.1% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.0% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 6.7% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.6% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.3% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 76.2% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 1.5% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.4% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.3% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 2.2% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 19.3% | 26.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 30.7% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.48 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.25 | 2.33 | 1.80 | worse |
‡ 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.
40.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.8% 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 29 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.9%CMS range 28.9–53.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 8.0–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 34.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 44.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 3.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.4–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 52 beds and averages 43.9 residents a day — about 84% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 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 3.02 hrs/resident/day on weekends vs 3.73 on weekdays — 19% thinner on weekends. RN hours go from 0.24 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2023-04-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident, (Resident #13) of 14 sampled residents, was free from a significant medication error. Staff failed to transcribe the resident's order for prednisone (steroid) correctly following his/her discharge from the hospital and return to the facility on 2/8/23. The facility administered 30 milligrams (mg) of prednisone daily for 46 days instead of the ordered three day tapered dose. As a result, the resident presented to the emergency room on 3/26/23 with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), steroid induced hyperglycemia (excessive amount of sugar in the blood), tachycardia (heart rate that exceeds the normal resting rate; a rate over 100 beats per minute is considered tachycardic) dependent edema (excessive fluid build up), dyspnea (shortness of breath) and glucosuria (excretion of glucose in the urine). The resident required further inpatient treatment and was admitted to 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.
- Actual harm · Gcited before2019-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Review of Resident #29's care plan, dated 9/11/18, showed the following: -The resident was at risk for falling related to balance impairment and confusion; -The resident often refused assistance. Staff should re-approach the resident often and check on the resident frequently because he/she did not use the call light; -Give the resident verbal cues to use the assist device and keep it reach at all times; -If the resident is observed attempting unsafe tasks, walk the resident to the couch by the nurse's station to be in line of sight of staff; -Attempt to toilet the resident before and after each meal and during bed checks. Review of the resident's Significant Change in Status Assessment Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/18, showed the following: -Diagnoses included dementia and anxiety; -Required extensive assistance of one staff for bed mobility, transfers, walking, toilet use, and hygiene; -Utilized a walker -One fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review , the facility failed to serve food under sanitary conditions in accordance with professional standards for food service safety, failed to follow proper hygienic practices when preparing and serving food to residents, including using hand hygiene techniques, and failed to ensure food service equipment and surfaces were appropriately cleaned and ceilings above food preparation and serving areas were maintained. The facility census was 42. Review of the facility's policy, Food Preparation and Service General Guidelines, last revised November 2022, showed the following: -Cross contamination can occur when harmful substances, i.e., chemical, or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods; -Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-08 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation or continued used of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Residents #16, #28, and #30) in a review of 15 sampled residents. The facility also failed to complete a 14-day review for the as needed (PRN) use of a benzodiazepine (a drug that produces sedation and hypnosis) for one resident (Residents #10). The facility census was 42. A review of the facility policy, Psychotropic Medication Use, dated July 2022, showed the following: -Policy Statement: Residents will not receive medications that are not clinically indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for infection control by failing to wash their hands or use hand sanitizer and properly use gloves when preparing and administering medications for one resident (Resident #17), and when providing personal care for three residents (Resident #10, #28 and #194), in a review of 15 sampled residents. The facility failed to place signage and follow indications for enhanced barrier precautions (EBP) (an infection control intervention that utilizes personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs)) for one resident (Resident #194), who required enteral feedings (a tube inserted into the stomach to provide an alternate route for nutrition when a person cannot swallow), and failed to follow facility policy for Legionella Surveillance and Detection for one resident (Resident #9). The facility failed to develop a policy to address Legionella Control that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 implement a system to ensure staff did not administer insulin (a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells throughout the body) or insulin-like products beyond the manufacturer's guidelines once opened for one resident (Resident #16) in a review of 15 sampled resident and one additional resident (Resident #5). The facility census was 42. Review of the manufacturer's guideline for use for Lantus insulin (long-acting insulin) showed it was good for 28 days after it was opened. Review of the manufacturer's guideline for use for Victoza (insulin-like medication) showed it was good for 30 days after it was opened. Review of the manufacturer's guideline for use for Toujeo insulin (long-acting insulin) showed it was good for 56 days after it was opened. Review of the manufacturer's guideline for use for Humulin R insulin (short-acting insulin) showed it was good for 31 days after it was opened. Review of the manufacturer's guideline for use for Aspart insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-15 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for three residents, (Resident #2, #1 and #3), when staff failed to remain with the resident when staff administered medications, and failed to ensure staff did not leave medications in the resident's room for one resident (Resident #1), when the resident did not have an order to keep medications at bedside or to self-administer, in a sample of four residents. The facility census was 43. Review of the facility policy, Administering Oral Medications, dated (revised) October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications; -Remain with the resident until all medications have been taken. The facility did not provide a policy for medications left at the resident's bedside. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an allegation of misappropriation of a resident's medications to the state survey agency, when the director of nurses (DON) received information an unnamed resident was hoarding his/her pain medications and giving them to a Certified Nursing Assistant (CNA) employed by the facility, who in turn was giving them to his/her spouse, also employed by the facility, in a review of four sampled residents. The facility census was 43. Review of the facility policy, Abuse Prevention Program, dated (revised) August 2006, showed the following: -The residents of the facility have the right to be free from abuse, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. Review of the facility policy, Reporting Abuse to Facility Management, dated (revised) April 2014, showed the following: -It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to immediately report any incident or suspected incident of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to investigate an allegation of misappropriation of a resident's medications, when the Director of Nurses (DON) received information that an unnamed resident was hoarding his/her pain medications and giving them to a Certified Nursing Assistant (CNA) employed by the facility, who in turn was giving them to his/her spouse, also employed by the facility, in a review of four sampled residents. The facility census was 43. Review of the facility policy, Abuse Prevention Program, dated (revised) August 2006, showed residents of the facility have the right to be free from abuse, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. Review of the facility policy, Reporting Abuse to Facility Management, dated (revised) April 2014, showed the policy did did not include the responsibility to investigate allegations or occurrences of abuse, neglect, or misappropriation and to share the results of the investigation to the state agency. During an interview on 08/15/24 at 3:20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 resident (Resident #5), in a review of five sampled residents, received the necessary care and treatment to prevent and/or heal pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin, most often on bony areas of the body). Staff failed to ensure the resident, who had a pressure ulcer on his/her right buttock, had a dressing in place on the wound as ordered and a Roho cushion (pressure relieving cushion) in his/her wheelchair when he/she was up sitting in the wheelchair. The facility census was 42. Review of the facility's wound care policy, revised October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -The following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The name and the title of the individual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The census was 44. 1. Review of the policy, Ice Machines Cleaning and Maintenance Procedure, dated 12/7/20, showed ice and ice-making machines may be contaminated through improper handling of ice by patients and/or staff, improper storage of ice, poor cleaning or maintenance of associated equipment and ice handling equipment/implements. Ice from contaminated ice machines may result in adverse events for patients. These include colonization of microorganisms, blood stream infections, gastrointestinal illness, surgical site and skin infections, and respiratory infections including Legionnaires' disease. Observation on 3/20/23 at 9:11 A.M., showed the ice machine in kitchen had white debris and white dried runs and deposits on the exterior. The interior of the ice machine had a buildup of white crusty debris and dark colored debris on the plastic above the accumulated ice. Observation on 3/20/23 at 10:30 A.M., showed the front of the ice machine had a gray plastic vent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-24 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD), and failed to perform detection and surveillance of possible cases of LD. The facility failed to ensure staff washed their hands and changed soiled gloves after direct resident contact and when indicated by facility policy to prevent the spread of infection during personal care for one resident (Resident #38 ) and during medication administration for four residents (Residents #31, #38, #5, and #13), in a review of 14 sampled residents, and for two additional residents (Residents #32 and #26). The facility census was 44. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Ecited before2023-04-24 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 follow physician orders for one resident (Resident #36) of 14 sampled residents, when staff did not ensure ordered medications at hospital discharge were transposed correctly. The resident did not receive a treatment as ordered to disinfect his/her skin from a methicillin-resistant staphylococcus aureus (MRSA) infection (a contagious bacterial infection of the skin). The facility also failed to obtain physician orders for treatments before performing them and did not check or change applied dressings timely for one resident (Resident #345). The census was 44. Review of the facility policy titled, Medication and Treatment Orders, revised July 2016, showed the following: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Policy Interpretation and Implementation: 1. Medications shall be administered only upon the written order of a person duly licensed 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.
- Potential for harm · E2023-04-24 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy addressing cardiopulmonary resuscitation (CPR) requirements for staff. The facility failed to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency services arrived. The facility had no system to ensure staff were certified in CPR for Healthcare Providers to include a hands-on and in-person skills assessment. Facility staff identified 11 residents as being full code status. The facility also failed to ensure the code status for one resident (Resident #39) matched in all areas of the medical record and all areas which listed the resident's code status. The facility census was 44. Review of the facility policy Emergency Procedure - Cardiopulmonary Resuscitation, last revised February 2018, showed the following: Policy Statement: Personnel have completed training on the initiation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely safely transport two (Residents #17 and #245) of 14 sampled residents and four additional residents (Resident #11, #21, #28, and #29) in wheelchairs by ensuring footrests were in place. Facility staff also failed to transfer Resident #11 appropriately with a gait belt. The facility census was 44. The facility did not have a policy that addressed how to safely transport a resident in a wheelchair. Review of the undated facility policy, taken from the Nurse Assistant in a Long-Term Care Facility, Restorative Nursing training, lesson plan four, unit VII, showed the following: -STEPS OF PROCEDURE FOR AMBULATING RESIDENT USING A GAIT BELT: Wash your hands. Identify and greet resident. Identify self. Explain what you are going to do. Lower bed to lowest level; assist resident to sit on edge of bed. Pause and allow resident to sit on edge of bed a few moments to regain balance. Assist resident in putting on nonskid shoes and socks. Put…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-24 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails/assist bars prior to installation and quarterly thereafter; failed to document interventions attempted prior to the use of bed rails/assist bars; failed to complete a bed rail entrapment assessment; and failed to review the risks and benefits with the residents/resident representatives and obtain consent for the use of bed rails/assist bars prior to installation for one resident (Resident #20), in a review of 14 sampled residents, and for two additional residents (Residents #1 and #7). The facility census was 44. Review of the facility's Proper Use of Side Rails Policy, revised December 2016, showed the following: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -Side rails are only permissible if they are used to treat a resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-24 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
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 two nurse aides (NA H and NA B) completed a nurse aide training program within four months of their employment in the facility. The facility census was 44. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Policy Statement: Nurse aides must undergo a state-approved training program; -Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. This term may also include an individual who provides these services through an agency or under a contract with the facility, but is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay; -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and -That individual has completed a training program 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.
- Potential for harm · E2023-04-24 · tag F0881 — failed to use antibiotics responsibly — patternImplement 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 develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 44. Review of the facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes Policy, revised December of 2016, showed the following: -Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form; -The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship; -As part of the antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP) or designee; -The IP or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; -Therapy may require further review and possible changes if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-24 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 offer and vaccinate eligible residents with pneumococcal vaccines as indicated by the current Centers for Disease Control (CDC) guidelines, for four residents (Residents #5, #11, #17, #38), in a review of 14 sampled residents. The facility census was 44. Review of the facility policy titled Pneumococcal Vaccine, revised August 2016, showed the following: -Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to facility unless medically contraindicated or the resident has already been vaccinated; 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-24 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide documentation to show staff inspected bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one resident (Resident #20), in a review of 14 sampled residents, and for two additional residents (Residents #1 and #7). The facility census was 44. Review of the facility's Proper Use of Side Rails Policy, revised December 2016, showed the following: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the risk of entrapment from the use of side rails and the bed's dimensions are appropriate for the resident's size and weight; -The resident will be checked periodically for safety relative to side rail use; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-24 · tag F0636 — isolatedAssess 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 record review and interview, the facility failed to complete an admission Minimum Data Set (MDS), (a federally mandated assessment instrument) in the time frame required by Centers for Medicare and Medicaid (CMS) for one newly admitted resident (Resident #145), in a sample of 14 residents. The facility census was 44. Review of the Resident Assessment Instrument (RAI) manual, revised October 2019, showed the following: -admission refers to the date a person enters the facility and is admitted as a resident. A day begins at 12:00 A.M. and ends at 11:59 P.M. regardless of whether admission occurs at 12:00 A.M. or 11:59 P.M., this date is considered the 1st day of admission; -Completion of an Omnibus Budget Reconciliation Act (OBRA) admission assessment must occur in any of the following admission situations: when the resident has never been admitted to this facility before; OR when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-24 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a baseline care plan that accurately reflected the resident's needs to include instructions needed to provide effective and person-centered care within 48 hours of admission, and failed to give a written summary of the baseline care plan to the resident/resident representative for one newly admitted resident (Resident #145) in a review of 14 sampled residents. The facility census was 44. Review of the facility's policy Baseline Care Plan, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The interdisciplinary team or licensed nurse will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to the following: a. Initial goals based on admission orders: b. Physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise care plans timely with changes in condition for two residents of 14 sampled residents (Residents #345 and #37). The facility census was 44. Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, showed the following: -Policy Statement: 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; -Policy Interpretation and Implementation: I. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -13. Assessments of residents are on-going and care plans are revised as information about the residents and the residents' condition change; -14. The interdisciplinary team must review and update the care plan:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent a urinary tract infection (UTI) for one resident (Residents #345) with an indwelling urinary catheter (a tube inserted into the bladder to drain urine), and failed to include the presence/care of the urinary catheter in the care plan in a review of 14 sampled residents. The facility census was 44. The facility did not provide a policy for indwelling urinary catheters or prevention of urinary tract infections. 1. Review of Resident #345's care plan dated, 10/26/21, showed his/her diagnoses included history of urinary tract infections: -It did not include the presence of a urinary catheter; -It did not provide instruction on the care of a urinary catheter. Review of the resident's Physician Order Sheet (POS), dated March 2023, showed the following: -Diagnoses included benign prostatic hypertrophy(enlarged prostate gland) (BPH) and lower urinary tract infection; -Urinary catheter, change monthly and as needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #17), in a review of 14 sampled residents, received the necessary services and assistance to maintain his/her nutritional status and to prevent weight loss. The facility census was 44. Review of the facility's policy, revised October 2017, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time; -The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss; -The staff and physician will identify pertinent interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-08-01 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #2's care plan, dated 9/25/18, showed the following: -The resident had poor memory/recall related to dementia; -The resident often forgot what he/he had been told. The resident obsessed about his/her shower through the early morning hours; -Allow the resident to sit on the couch and wait for his/her shower and redirect the resident with validation, redirection, and distraction techniques. Review of the resident's care plan, dated 10/29/18, showed the following: -The resident could be disruptive by asking for showers over and over. Staff should try offering snacks and reminding the resident he/she had already had a shower; -The resident has anxiety and was most anxious when he/she wanted to take a shower. The resident would ask to take more than one shower a day and would ask repeatedly for a shower when he/she was anxious. Remind the resident he/she had already had a shower and could take another shower tomorrow; -Offer the resident snacks or something to do to help with anxiety. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-08-01 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 staff served the correct portion size of protein per the dietary spreadsheet menu to all residents with a physician's order for a mechanical soft diet and failed to offer or serve bread to all residents with an order for a regular or mechanical soft diet. The facility census was 39 residents. 1. Review of the Order Report by Category, dated 6/29/19 to 7/29/19, provided by the Dietary Manager, showed nine residents had a physician's order for a mechanical soft diet. Review of the Diet Spreadsheet, Week 3, Day 16, showed residents on a mechanical soft diet were to receive a #8 (1/2 cup) serving of ground pork chop with gravy. Observation on 7/29/19 at 11:40 A.M. showed Dietary Staff A placed a #10 scoop in the pan of ground pork chops with gravy. He/She began plating the lunch meal. Observation on 7/29/19 at 12:29 P.M. showed the lunch meal service ended. Staff served all residents on a mechanical soft diet a #10 scoop (3/8 cup) of ground pork chops with gravy instead of a #8 scoop (1/2 cup) as directed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-04-24 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to give appropriate Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMS-10055) and the CMS Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing to two residents of three sampled residents(Residents #4 and #17), or the resident's representatives, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 44. During an interview on 3/22/23 at 4:45 P.M., the Administrator (ADM) said the facility does not have a policy for SNF ABN CMS-10055 and the CMS NOMNC CMS-10123 forms. 1. Review of Resident #4's entry tracking Minimum Data Set (MDS), dated [DATE], showed the resident was admitted to the facility on [DATE]. Review of the SNF Beneficiary Protection Notification Review form completed by the facility showed the facility documented: -Medicare part A Skilled Services started 1/30/23; -Last covered day of Part 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.
- No harm found · B2023-04-24 · tag F0623 — patternProvide 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 interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or resident representative when two of 14 sampled residents (Residents #13 and #17) and one additional sampled resident (Resident #18), were transferred to the hospital. The facility did not provide any written documentation to the resident or resident representative of the reason and date for the transfer/discharge, where the resident was to be transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, and how to contact the mental health advocacy group for resident with intellectual disabilities or mental illness. The facility census was 44. During an interview on 3/28/23 at 3:45 P.M., the Director of Nursing (DON) said the facility did not have a written policy for providing written notice upon transfer/discharge. There was no written document for the resident/resident representative with the reason for transfer/discharge, the effective…
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.
- No harm found · B2023-04-24 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 a written notice of bed hold policy to the resident and/or resident representative for two of 14 sampled residents (Residents #13, and #17) and one additional resident (Resident #18), when they were transferred to the hospital. The facility census was 44. 1. Review of Resident #13's Face Sheet showed the resident was admitted to the facility on [DATE]. Diagnoses include Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Raynauds' (spasms in extremities worsens with cold restricting blood flow causing numbness, and pain), Corticobasal degeneration (nerve cells controlling movement degenerate). Resident has an emergency contact, but no guardian or power of attorney listed. Review of the resident's nurses notes, dated 11/1/22, showed the following: -Resident was unresponsive; -Blood pressure 76/50 (normal range 120/80 millimeter of mercury (mm Hg) and 90/60 mm Hg), pulse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HRUSKA, APRIL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/05/2020 |
| DANIELS, LANA | Individual | CORPORATE OFFICER | since 04/04/2014 |
| LA PLATA NURSING HOME DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 06/12/1967 |
| BELL, AURORA | Individual | GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | since 07/01/2024 |
CMS files one row per role, so the 7 rows in the source record cover these 4 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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265793. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-08, 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.