Lee's Summit Place
1501 SW 3rd Street, Lees Summit, MO 64081 · For profit - Limited Liability company · 60 certified beds · (816) 525-6300 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- 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 payroll-based staffing rating is low (1/5)
- nursing-staff turnover (74%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 5.3% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 97.3% | 18.5% | 6.5% | worse 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 | 5.1% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.8% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.4% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.8% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.2% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 92.2% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.9% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.1% | 13.7% | 12.0% | 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.
54.0% 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 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 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 0.69 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 54.0%CMS range 45.1–62.0 | 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 | 10.8%CMS range 7.7–14.4 | 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 | 50.0% | 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 | 57.7% | 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 | 46.1% | 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 | 88.2% | 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 | 96.4% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 97.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 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 | 7.1%CMS range 4.0–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 60 beds and averages 56.4 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.46 hrs/resident/day on weekends vs 3.08 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.96 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 74% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-04-07 · 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 follow the facility's policies; failed to ensure prevention and treatment of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); failed to identify individuals at risk for developing pressure injuries; failed to assess, monitor, and measure the wounds at least weekly and document the findings; failed to observe for changes in the pressure injury that could indicate a change in the treatment; failed to implement the interventions on the residents plan of care; and failed to follow physician's orders for the treatment of pressure injuries for two sampled residents (Resident #26 and #307) out of 12 sampled residents. The facility census was 48 residents. Review of the facility policy titled Comprehensive Care Plan, dated 9/1/21, showed: -It was the policy of the facility to develop and implement a comprehensive…
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 · D2026-05-26 · 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 On 5/26/26, the Administrator was notified of the past noncompliance which took place on 5/11/26. The resident's physician was notified of the error. The Director of Nursing (DON) provided facility staff training on 5/11/26 with return demonstration provided. The deficiency was corrected on 5/11/26. Review of facility policy entitled Medication Administration revised 2/7/24 showed:-Medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Identified resident by photo in the Medication Administration Record (MAR).-Review MAR to have identified medication to be administered. -Compare medication with MAR to have verified resident name, medication name, form, dose, route, and time. -Observed resident consumption of medication. 1.Review of Resident #2 admission Record showed the resident admitted to the facility on [DATE] with the following diagnosis:-Essential…
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 · Dcited before2025-04-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 medications were given as ordered when a staff member administered Lorazepam Intensol (a scheduled IV controlled substance medication was used for the management of anxiety disorders (a feeling of fear, dread, and uneasiness) without a physician's order for one supplemental resident (Resident #14) out of 12 residents. The facility census was 48 residents. Review of the facility policy titled Medical Provider Orders, dated 4/7/22, showed: -The facility shall use uniform guidelines for the ordering and following of medical provider orders. -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. -Documentation of medication if using electronic medication record, should be input in the electronic health record (EHR) with instructions per facility policy. -Medical provider orders should be reviewed prior to administration of medication to validate the orders timely. -If an order does not contain…
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 · D2025-04-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess the resident's ability and capacity for self-care of his/her catheter (a tube passed through the urethra into the bladder to drain urine); failed to provide the resident with infection control education for self-administration of his/her catheter to help prevent infection; failed to capture the resident's self-catheter care on his/her admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning); and failed to include the resident's self-care on his/her baseline care plan for one sampled resident (Resident # 307), out of 12 sampled residents. The facility census was 48 residents. A policy was requested and not received at the time of exit. 1. Review of Resident #307's admission record, dated 3/25/25, showed he/she admitted with the following diagnoses: -Cognitive communication deficit. -Neuromuscular dysfunction of the bladder (lack of bladder control due to brain,…
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 · Dcited before2025-04-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate documentation on the narcotic count sheets; and failed to dispose of Lorazepam Intensol (a controlled substance used to treat anxiety) per professional standards and facility policy for one supplemental resident (Resident #14). The facility census was 48 residents. Review of the facility policy titled Controlled Substance Administration & Accountability, dated [DATE], showed: -It was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. -Where an automated patient profiling systems is not utilized, the Director of Nursing (DON), charge nurse, and other designee and the consultant pharmacist discuss all additions or deletions to the areas stock supply. -All controlled substances (schedule II, III, IV, 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 · Fcited before2023-09-08 · 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 keep the kitchen and Dry Storage (DS) room floors clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; 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 13 residents with a licensed capacity for 60 residents at the time of the survey. 1. Review of the meal times provided by the Dietary Manager (DM) on 9/5/23 at 8:48 A.M. showed that breakfast was served at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:30 P.M. Observation on 9/5/23 between 8:48 A.M. and 9:17 A.M. during the initial kitchen inspection showed the following: -There was a large amount of unknown residue on the manual can opener blade. -There were grease drips along the lower edge of 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.
- Potential for harm · E2023-09-08 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an annual dental exam for two sampled residents (Resident #2 and Resident #5) and to provide a dental consult for one sampled resident (Resident #12) who wanted to be evaluated for possible extractions of his/her teeth so he/she could obtain dentures out of nine sampled residents. The facility census was 13 residents. Review of the facility's dental services policy revised on 9/1/22 showed: -It was the policy of the facility to assist residents in obtaining routine and emergency dental care. -The dental needs were to be identified through the physical assessment and Minimum Data Set (MDS-a federally required assessment tool completed by facility staff for care planning) assessment process and addressed in each resident's plan of care. -Oral/dental status should be documented according to assessment findings. -Residents and/or resident representative were notified of dental services available during the admission process. -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 · Ecited before2023-09-08 · 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 perform hand hygiene during cares for one sampled resident (Resident #12); to ensure nursing staff were cleansing their hands during medication pass, did not sanitize a pair of scissors used to open an sealed package counting a narcotic, and picked a tray lid up off of the floor without cleansing hands for one sampled resident (Resident #10) out of nine sampled residents and to follow their policy to complete testing to screen new employees and residents 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 two out of ten sampled new employees. The facility census was 13 residents. Review of the facility's hand hygiene policy dated 9/1/21 showed: -All staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. -Hand hygiene should be 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 · D2023-09-08 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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' private records were kept private during a medication pass by not ensuring the computer screen was not visible to anyone walking by the computer on top of the medication cart while the nurse administered medications inside of the residents' room for two sampled residents (Resident #5 and Resident #11) and one supplemental resident (Resident # 10) out of nine sampled residents. The facility census was 13 residents. Review of the facility's policy, Medication Administration, dated 9/1/22 showed: -Medications were to have been administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Provide privacy. 1. Review of Resident 5's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Cognitive communication deficit (a disorder in which a person has difficulty communicating as…
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 · D2023-09-08 · 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 interview and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for one sampled resident (Resident #269) out of nine sampled residents. This practice had the potential to effect the resident's safety and physical well-being. The facility census was 13 residents. Review of the facility's Comprehensive Care Plans Policy, dated 9/1/2021, showed: -It was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident. -The comprehensive care plan described the services that were furnished to attain or maintain the resident's highest practicable physical well-being. -The comprehensive care plan was prepared by the interdisciplinary team which included: --The attending physician. --A Registered Nurse (RN). --A nurse aide. --A member of the food and nutrition services…
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 · Dcited before2023-09-08 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 document information regarding the resident's personal belongings for one sampled closed record resident (Resident #15) out of two sampled closed records. The facility census was 13 residents. Review of the facility's resident personal belongings policy revised 9/1/22 showed: -All resident personal belongings would be inventoried at the time of admission and documentation kept in the medical record. -Additional possessions brought in during the duration of the individual's stay would be added to the existing personal belongings inventory listing. -Following the discharge of a resident, all personal belongings would be given to the designated resident representative. -The inventory of personal belongings should be reviewed at time of discharge by Social Services and the resident's representative. -The recipient of the resident's personal belongings would sign-off with their legal signature acknowledging receipt of all personal belongings presented. 1.…
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 19 citations
- Potential for harm · D2023-09-08 · 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
Based on observation, interview and record review, the facility failed to follow physician orders by not providing supervision for one sampled resident (Resident #269) out of nine sampled residents while the resident was alone in his/her wheelchair in his/her room. The facility census was 13 residents. Review of the facility's Medical Provider Orders policy, dated 4/7/22, showed: -The facility used uniform guidelines for the ordering and following of medical provider orders. -Medical provider orders were reviewed prior to administration of medication and/or treatment to validate the orders contained all required elements. -Staff should follow all valid medical provider orders timely unless there was an emergency that temporarily delayed the implementation of the order. Review of the facility's Incidents and Accidents policy, dated 9/1/22, showed: -The purpose of the policy was to ensure appropriate and immediate interventions were implemented and corrective actions taken to prevent recurrences and improve the management of resident care. 1. Review of Resident #269's face sheet,…
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 · D2023-09-08 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
Based on observation, interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #68) who was the only resident receiving dialysis that resided at the facility. The facility census was 13 residents. Review of the facility's dialysis policy revised 9/1/22 showed: -There should be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. -The facility staff should coordinate and collaborate with the dialysis facility to assure that documentation requirements were met to assure that treatments are provided as ordered. 1. Review of Resident #68's all-inclusive admission with baseline care plans dated 9/3/23 showed the reason for the resident's admission was to receive therapy, cares and dialysis. Review of the resident's Physician's Order Sheet dated September 2023 showed: -The resident was to receive dialysis from 5:00 A.M. to 9:00 A.M. -The resident's dialysis days were Monday, Wednesday and Friday.…
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 · D2023-09-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for one sampled resident (Resident #268) out of five residents sampled for immunizations. The facility census was 13 residents. Review of the facility's Pneumococcal Vaccine Policy, dated 9/1/2021, showed: -It was the facility's policy to offer residents immunizations against pneumococcal disease in accordance with current Center for Disease Control (CDC-the nation's health protection agency responsible for controlling the introduction and spread of infectious diseases) guidelines and recommendations. -Each resident was assessed for pneumococcal immunization upon admission. -Each resident was offered the pneumococcal immunization unless medically contraindicated or the resident was already immunized. -Vaccinations were offered to residents 65 years or older, according to CDC guidelines. -The resident's medical record included documentation that indicated 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 · F2022-05-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 14 residents. Record review of the facility policy Nurse Staffing Posting Information revised 5/1/22 showed: -The daily staffing sheet would be posted on a daily basis and contain the following information: --The facility name. --The current date. --The census. --The total number of hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and Certified Nurses Assistants (CNA's). -The information would be clear and in a readable format. -The information would be in a prominent place readily accessible to residents and visitors. 1. Observation on 5/2/22 at 5:40 A.M. showed a staffing sheet posted on 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 · Fcited before2022-05-05 · 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 keep the dry storage floor clean; failed to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; and to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 14 residents with a licensed capacity for 60 residents. 1. Observations during the initial kitchen inspection on 5/2/22 between 9:26 A.M. and 10:18 A.M. showed the following: -The dry storage room had numerous plastic lids, dried drips, paper debris, and a leaf on the floor under storage racks. -The microwave had an excessive build-up of food splatters on the upper inside, with some also on the sides and inner side of the door. -A light bulb with socket inside the reach-in refrigerator by the stove was hanging down loose from the inner…
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 · F2022-05-05 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment updated annually and complete to show the current resident population and needs. A total of 8 residents were sampled. The facility census was 14 residents. Record review of the facility's Facility Assessment policy revised 5/1/22 showed: -The facility conducted and documented a facility wide assessment to determine what resources were necessary to care for the residents competently during both day-today operations and emergencies. -The facility assessment would be reviewed and updated whenever there was, or the facility plans for, any change that would require a substantial modification to any part of the assessment or at a minimum, annually. 1. Record review of the Facility Assessment Tool dated 3/30/20 and updated…
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 before2022-05-05 · 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 meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility; failed to follow facility policy to ensure staff completed employee tuberculosis (TB-a potentially serious infectious bacterial disease that mainly affects the lungs) testing according to professional standards for three employees (Employee D, E, and F) out of eight sampled employees; failed to ensure infection control practices to prevent possible cross-contamination during the medication…
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 · F2022-05-05 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, well graded driving surface to prevent the pooling of water, in the event of an evacuation of residents, and/or for emergency and transport vehicles. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility. The resident census was 14 residents with a licensed capacity for 60 residents. 1. Record review of the facility's disaster manual entitled Master Emergency Book, last reviewed and updated on 12/12/18 and obtained from the nurse's station, showed the following: -On the page entitled Evacuation Considerations, under point #4, which was a list of evacuation terms, at part c, it stated, Complete/Outside Evacuation: Moving residents, staff, and visitors to a pre-designated area outside of the building. -An accompanying map of the facility had the main parking lot outside the front entrance marked as the Final Meeting Place. -On the page entitled Plan of Action for Evacuation Procedures 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.
- Potential for harm · E2022-05-05 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for the use of supplemental oxygen, as needed pain medication including non-pharmacological interventions, anticoagulant use and diuretic use for three sampled residents (Resident #7, #4, and #13) out of eight sampled residents. The facility census was 14 residents. 1. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's care plan dated 9/25/20 and last revised on 4/12/22 showed no care plan for the resident's supplemental oxygen, or for his/her diuretic (fluid removing medication) use. His/Her pain care plan did not include non-pharmacological interventions for pain management. Record review of the resident's May 2022 Physician's Order Sheet (POS) showed: -Check oxygen saturation every shift. If below 90 percent (%), may use oxygen as ordered as needed. --NOTE: The resident did not have an active order for the use of supplemental oxygen. 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 · Ecited before2022-05-05 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 Acetaminophen (an over the counter pain medication) orders were clarified to include parameters for maximum dose per day for four sampled residents and to provide and document non-pharmacological interventions prior to administering as needed pain medication for four sampled residents (Residents #7, #8, #4, and #13) out of eight sampled residents. The facility census was 14 residents. A policy for the use of non-pharmacological interventions prior to administering as needed pain medications and a policy for medication parameters, including Acetaminophen was requested and not received at the time of exit. Record review of Micromedex on 5/3/22 showed: -The maximum dose for Extra Strength Acetaminophen is 3000 milligrams (mg) in 24 hours. -For fever or mild to moderate pain, the maximum dose for regular strength acetaminophen is 3250 mg per 24 hours. 1. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE].…
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 · E2022-05-05 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were free from medication administration error rate of less than five percent (5%). A total of three medication errors out of 31 opportunities were observed for a medication error rate of 9.67% affecting three residents (Residents #12, #165, and #13). The facility census was 14 residents. Record review of the facility Medication Administration Policy dated 5/1/22 showed: -Staff were directed to administer medications as ordered by the physician in accordance with professional standards of practice. -Compare the medication with the resident's Medication Administration Record (MAR) to verify the resident, the medication, and the time the medication was to be administered. -A list of medications that were not all-inclusive that were directed to be given on an empty stomach included Levothyroxine (a thyroid medication)and Claritin (Loratadine - a medication for allergies). Record review of Micromedex on 5/4/22 showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-05 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 medications were labeled correctly, expired medications were properly disposed of, and medications were stored at the appropriate temperature. This deficient practice potentially affected all residents who received medications from the medication cart and medication storage room. The facility census was 14 residents. 1. Observation on 5/4/22 at 7:42 A. M., of the resident's medication administration with Agency Licensed Practical Nurse (LPN) A showed: -Acidophilus (a probiotic supplement) was pulled from the medication cart. --The bottle was opened on 4/23/22. --The bottle was the same temperature as all other over-the-counter (OTC) medications in the medication cart. --The bottle of Acidophilus showed it must be refrigerated after opening. During an interview on 5/4/22 at 8:41 A.M. Agency LPN A said he/she did not know that Acidophilus needed to be refrigerated. 2. Observation on 5/4/22 at 8:45 A.M., of the Certified Medication Technician (CMT) Medication Cart showed: -Timolol (eye drops that help…
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 · E2022-05-05 · tag F0885 — failed to notify residents/families about COVID-19 — patternReport COVID19 data to residents and families.
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 and/or family were notified when a staff or resident in the facility tested positive for COVID (a new disease caused by a novel (new) coronavirus) for one sampled resident (Residents #8) out of one sampled resident who resided at the facility between November 2021 through January 2022 when the facility reported having positive cases in the building. The facility census was 14 residents. 1. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's medical record from 11/21/21 to 1/20/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 2. Record review of the facility social media account showed the last post notifying residents and family of a COVID positive resident and a COVID positive staff was on 1/13/22. Record review of the facility COVID Timeline provided by the facility Administrator on 5/5/22…
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 · E2022-05-05 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 provision and documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine for unvaccinated residents upon admission to the facility for two sampled residents (Residents #265 and #117) out of eight sampled residents. The facility census was 14 residents. Record review of the facility COVID-19 Vaccination policy dated 11/5/21 showed: -The facility will follow guidance from the Centers of Disease Control and Prevention (CDC) and any additional State and local guidelines and regulations. -Our facility will offer COVID-19 vaccinations to residents per CDC and/or Food and Drug Administration (FDA) guidelines and State and local guidelines and regulations unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine due to religious reasons.…
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 · E2022-05-05 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 standard trash and garbage disposal practices to mitigate the presence of common household pests, specifically ants, and to maintain an effective pest control program with adequate measures to eradicate those pests when present. These deficient practices potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen and/or resided, visited, used, or worked in the facility. The facility's census was 14 residents with a licensed capacity for 60 residents. 1. Observations during the initial kitchen inspection on 5/2/22 between 9:26 A.M. and 9:52 A.M. showed the following: -There were three ants crawling inside a microwave and numerous ants on its outer top and sides. -An unlidded large garbage can, approximately 4/5 full with food scraps on top, had its lid in between the floating prep table and steam table. -Another large garbage can in the dishwashing area was unlidded with its lid tucked 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.
- Potential for harm · D2022-05-05 · tag F0623 — isolatedProvide 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 notify the resident in writing of a transfer or discharge to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for one sampled resident (Resident #6) out of eight sampled residents. The facility census was 14 residents. Record review of the facility's Transfer and Discharge policy revised 5/1/22 showed the staff were to provide a transfer notice upon transfer to the resident and/or the residents' representative as soon as practical. 1. Record review of Resident #6's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled rehabilitation stay and was his/her own responsible party. -Had the following diagnoses: --Stroke. --Dysphagia (inability or difficulty swallowing). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated…
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 · D2022-05-05 · tag F0625 — isolatedNotify 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 notify the resident in writing of the facility bed hold policy at the time of transfer for one sampled resident (Resident #6) out of eight sampled residents. The facility census was 14 residents. Record review of the facility's policy Bed Hold Upon Transfer revised 5/1/22 showed before a resident was transferred to the hospital, the facility would provide a written notice which specified the duration of the bed hold policy. 1. Record review of Resident #6's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled rehabilitation stay and was his/her own responsible party. -Had the following diagnoses: --Stroke. --Dysphagia (inability or difficulty swallowing). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be complete by facility staff for care planning) dated 2/21/22 showed he/she was cognitively intact. Record review of the resident's Nurses Notes dated…
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 · Dcited before2022-05-05 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 recapitulation of stay was completed and to document the disposition of medications upon discharge for one sampled resident (Resident #15); and to ensure a recapitulation of stay was completed and to document the disposition of medications and belongings for one sampled resident (Resident #16) who was discharged after a skilled therapy stay out of two sampled closed records. The facility census was 14 residents. A policy was requested but not received from the facility. 1. Record review of Resident #15's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled therapy stay. -Had the following diagnoses: --Pneumonia (inflammation of one or both lungs with consolidation). --Respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). --Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily 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.
- Potential for harm · D2022-05-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 a resident had a current, valid physician's order for supplemental oxygen who was utilizing as needed supplemental oxygen for one sampled resident (Resident #7) out of eight sampled residents. The facility census was 14 residents. 1. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's May 2022 Physician's Order Sheet (POS) showed: -Check oxygen saturation every shift. If below 90 percent (%), may use oxygen as ordered as needed. --NOTE: The resident did not have an active order for the use of supplemental oxygen. The resident had a previous order for oxygen as needed at 2 Liters (L) that was discontinued on 3/5/21. Observation on 5/2/22 at 5:31 A.M. showed the resident was lying in bed asleep. The resident was wearing supplemental oxygen. Observation on 5/2/22 at 8:46 A.M. and at 12:08 P.M., on 5/3/22 at 9:49 A.M. and 2:13 P.M., on 5/4/22 at 7:34 A.M., 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.
“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.
Part of a chain
This home belongs to VERTICAL HEALTH SERVICES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.3 | +1.7 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 14 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| VHS MO OPCO HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| VERTICAL HEALTH SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| VHS HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| VHS ULTIMATE PARENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| MILLER, WILLIAM | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
| 3RD ST CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2025 |
| BAX, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/23/2025 |
| TADAKAMALLA, SRINATH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/26/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 8 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.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $172K 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
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 265512. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.