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Loch Haven

701 Sunset Hills Dr, Macon, MO 63552 · Government - County · 100 certified beds · (660) 385-3113 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0744)1 immediate-jeopardy citation$77,841 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $77,841 in federal fines (most recent 2025-03-07)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
404 Providence Rd · (660) 395-8914 · Call to confirm hours
Pharmacy
115 Vine St · (660) 385-2167 · Call to confirm hours
Grocery
206 N Rollins St · (660) 385-2151 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
305 Sunset Hills Dr · (660) 395-3663

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 1 of 5
Short-stay residentsrehab / post-hospital 4 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 held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.4%18.1%15.4%worse
Long-stay residents who lose too much weight2.2%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection4.6%2.3%2.0%worse
Long-stay residents with depressive symptoms2.9%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.9%4.1%3.3%worse
Long-stay residents whose ability to walk worsened8.6%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.1%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.6%90.9%95.3%typical
Long-stay residents with pressure ulcers8.6%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control20.9%17.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table29.6%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine85.0%63.5%79.4%typical
Short-stay residents rehospitalized after admission10.8%26.0%22.6%better
Short-stay residents with an outpatient ER visit16.9%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.782.111.67typical
Long-stay outpatient ER visits per 1,000 resident days3.602.331.80worse

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

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

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

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

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

47.2% 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 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.2%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
65.0%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 65.0% 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 20 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 0.12 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.2%CMS range 37.0–59.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 5.8–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 2.8–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.39
RN hours/ resident / day
0.32
LPN hours/ resident / day
2.86
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.22
RN hoursweekends
29.8%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 71.5 residents a day — about 72% occupied, or roughly 28 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.86 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 3.20 hrs/resident/day on weekends vs 3.72 on weekdays — 14% thinner on weekends. RN hours go from 0.46 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

16
deficiencies at the latest standard inspection (2025-08-11)
6
at the previous standard inspection (2023-11-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to adequately monitor one resident's (Resident #1's) monitoring device (a small wristwatch-sized device (Tag) worn by a resident or attached to an asset (wheelchair, walker) that will trigger an alarm if in close proximity of an activation field; usually an exit door), per the manufacturer's instructions to ensure it functioned appropriately and would alert staff if the resident attempted to leave the facility without staff knowledge, in a review of 14 sampled residents. The resident was assessed as at risk for elopement and utilized a monitoring device as an intervention to address that risk. On 3/2/24 at 7:24 A.M., the resident exited the facility through the main entrance without staff knowledge in his/her motorized wheelchair. The monitoring device alarm system did not function and alarm when the resident exited the facility. The resident traveled approximately one half mile, on a paved road with no shoulder or side walk, before a concerned citizen saw the resident and contacted 911 and the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-03-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #2), in a review of seven sampled residents, received the necessary care and services in accordance with professional standards of practice when the facility failed to assess and report Resident #2's complaint of right eye pain, redness, watering, and blurry and dim vision timely. The resident was involved in a physical altercation with Resident #1 on 02/10/25, where both resided on the facility's Special Care Unit (SCU - dementia care unit). Resident #2 reported to family and staff in the days following that his/her eye hurt. Multiple staff in the SCU, including Certified Medication Technicians (CMT) and a Certified Nursing Assistant (CNA), reported to licensed staff (nurses that worked off SCU unit and were to go to that unit to assess any reported issue), the resident's complaints and concern with his/her right eye. Licensed staff failed to come to the unit to assess the resident's eye concerns reported by unit staff.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 identify the root cause of an altercation involving two residents (Residents #1 and #2), who had a diagnosis of dementia, in a review of seven sampled residents, following a physical altercation on 8/12/25, failed to effectively communicate the altercation to staff, and failed to develop individualized interventions to address the root cause and to prevent further incidents. On 8/15/25, Resident #2 approached Resident #1, in the same manner he/she did on 8/12/25, and knocked Resident #1 down with his/her walker. The facility census was 73. During an interview on 8/21/25 at 11:04 A.M., the Administrator said the following:-The facility did not have a policy for dementia care;-The facility did not have a policy for resident-to-resident altercations;-The facility had a policy for Wandering, but it was only specific to elopement risk and the functioning of Wanderguards (electronic monitoring devices). 1. Review of Resident #1's face sheet showed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, date, or store food items per manufacturer's instructions. Staff did not practice proper hand and glove hygiene, hair restraint usage, and consumption of personal food items. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris and did not ensure surfaces were sanitized properly. Staff did not ensure dishes and utensils were stored and handled in a sanitary manner. The facility census was 73. 1. Review of the facility policy, Food Storage (Dry, Refrigerator, and Frozen), dated 2020, showed the following:-Food shall be stored on shelves in a clean, dry area free from contaminants;-Food should be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety;-All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that enhanced residents' dignity and ensured full recognition of individuality for one resident (Resident #72), in a review of 18 sampled residents, and three additional residents (Residents #26, #32 and #57). The facility census was 72. Review of the facility policy, Assistance with Meals, revised March 2022, showed the following:-Residents shall receive assistance with meals in a manner that meets the individual needs of each resident;-Facility staff will serve resident trays and will help residents who require assistance with eating;-Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, - Do not stand over residents while assisting them with meals. 1. Review of Resident #26's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/22/25, showed the following:-Severely impaired cognitive skills for daily decision…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two residents (Residents # 27 and #72), in a review of 18 sampled residents, and one additional resident (Resident #26), were provided the right to choose schedules (including waking times) and make choices about aspects of their lives in the facility that were significant to the residents. The facility census was 72. Review of the facility policy, Quality of Life-Dignity, revised February 2020, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem;-Residents are treated with dignity and respect at all times;-The facility culture is one that supports and encourages humanization and individuation of residents and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay;-Some examples of ways in which…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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 electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #18) in a review of 18 sampled residents and five additional residents (Resident #15, #25, #30, #32 and #36). The facility's census was 72. The facility did not provide a policy for MDS assessment and transmission upon request. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, dated October 2024, showed the following: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date;-Encoding Data: Within 7 days after completing a resident's MDS assessment or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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

    Based on observation, interview and record review, the facility failed to review and revise the care plan for two residents (Resident #2 and Resident #72) in a review of 18 sampled residents, to reflect the resident's specific condition and/or needs. The facility census was 72. Review of the facility policy, Goals and Objectives, Care Plans, revised 2009, showed the following: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence; -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: -Are resident oriented; -Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and can report whether the desired outcomes are being achieved; -Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition and at least quarterly.;-The policy did not define expectations for review and revision of care plans. 1. Review of Resident #2's quarterly Minimum Data…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure chemicals were secured in a locked storage area and not accessible to residents. The facility failed to ensure the electric range, located in the north activity room was disabled when not in use and staff were not present. The facility census was 72. 1. Review of Resident #62's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/17/25, showed the following: -Cognitively impaired; -Diagnosis of non-Alzheimer's dementia (a group of conditions causing cognitive decline, impacting memory, thinking and behavior, that are not due to Alzheimer's disease). Observation on 08/06/25 at 4:10 A.M. on the 400 hall showed the following:-The shower room door was unlocked and accessible to residents;-No staff was present in the area;-Resident #62 walked up and down the hallway; -Two bottles of Lysol disinfectant cleaner sat on the floor by the toilet. The label read, Warning: Causes…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week and failed to ensure the Director of Nursing (DON) worked as a charge nurse only when the facility had a census of 60 or less. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25 showed the following:-Average daily census: 70;Staff included one Registered Nurse, Director of Nurses full time on days, an Assistant Director of Nursing (ADON) full time on days, and an RN or Licensed Practical Nurse (LPN), two for the day shift and one for night shift. 2.Review of the Licensed Nurse Schedule, dated January 2025, showed no hours of RN coverage for 01/01/25. Review of the Licensed Nurse Schedule, dated 01/07/25, showed no hours of RN coverage scheduled. Review of RN R's timecard, dated 01/07/25, showed he/she worked six hours and 45 minutes (did not fulfill the eight-hour requirement). 3.Review of the Census Activity Report, dated 01/11/25, showed the facility census was 68. Review of the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular 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 complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews. The facility census was 72. The facility did not provide a policy for annual performance reviews. 1.Review of a list of current staff, dated 08/05/25 showed the following:-Certified Nurse Aide (CNA) I: Date of hire 04/15/09;-CNA J: Date of hire 07/03/23;-CNA H: Date of hire 07/04/07;-CNA B: Date of hire 10/20/22;-CNA L: Date of hire 02/10/11. Record review showed no documentation of nurse aide evaluations or annual performance reviews for CNA B, CNA H, CNA I, CNA J or CNA L. During an interview on 08/11/25 at 6:04 P.M., the Director of Nursing (DON) said the following:-Nurse aide evaluations/annual performance reviews had not been completed for a while;-If there were complaints regarding staff performance or skills, the Registered Nurse (RN) Consultant proved additional training to that staff member. During an interview on 08/11/25 at 6:30 P.M. the Administrator said…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide food at an appetizing temperature. The facility census was 73. Record review of the facility policy, Serving Temperatures for Hot and Cold Foods, revised 2020, showed the following: -Food will be served at the following temperatures to ensure a safe and appetizing dining experience: -Vegetables - 135 degrees Fahrenheit (F) to 170 degrees F; -Fruits, desserts, and dairy products - 41 degrees F or below; -The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures will be recorded. 1. Review of food temperature logs, located in the kitchen, for all meals (breakfast, lunch, dinner) for 8/1/25, 8/2/25, and 8/3/25 were blank. 2. Review of the Diet Orders, printed 8/4/25, showed the following: -57 residents with a physician-ordered regular diet; -Nine residents with a physician-ordered mechanical soft diet; -Five residents with a physician-ordered pureed diet; -Two residents with a physician-ordered finger foods diet. 3.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · E2025-08-11 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 offered a nourishing bedtime snack to two residents (Resident #6 and Resident #11) in a review of 18 sampled residents and two additional residents (Resident #25 and Resident #50) when meals were served greater than 14 hours apart. The facility census was 72. The facility did not provide a policy for frequency of meals or bedtime snacks upon request. 1. Review of the undated Meals and Memories Cafe Mealtimes, posted by the dining room, showed the following:-Breakfast: 7:30 A.M. to 8:30 A.M.;-Lunch: 11:30 A.M. to 12:30 P.M.;-Supper: 4:30 P.M. to 5:30 P.M. (14 hours between the supper and breakfast meals). 2. Observation and interview of the facility resident council meeting on 08/05/25 at 11:00 A.M. showed the following: -Ten residents attended the meeting; -Some of the residents said they didn't receive routine snacks at bedtime. 3. During an interview on 08/05/25 at 11:06 A.M., Resident #11 said the following:-He/She did not routinely receive a bedtime snack;-He/She would take a bedtime snack if…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene in accordance with acceptable standards of practice to prevent the spread of infection for three residents (Residents #3, #40 and #45). The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP), as required by facility policy, when repositioning to one resident (Resident #6), who had a pressure ulcer with infection. The facility failed to ensure catheter drainage bags and tubing were kept off the floor to prevent risk of contamination for two residents (Residents #3 and #72), and failed to ensure nebulizer and bilevel positive airway pressure (BiPAP; a non-invasive ventilation method that delivers pressurized air to help individuals with breathing difficulties) masks were stored in accordance with facility policy for three residents (Residents #6, #11, and #3), in a review of 18 sampled residents. The facility census was 72. Review of the facility's undated Infection Control Policy…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0887 — pattern
    Educate 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

    Based on interview and record review, the facility failed to provide all staff with written documentation of education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine and failed to maintain documentation related to staff COVID-19 vaccination status. The facility census was 72. Review of the facility's COVID-19 Staff Vaccination policy, dated October 2022, showed the following:-Before offering the COVID-19 vaccine, the staff member is provided with education regarding the benefits and risks, and potential side effects associated with the vaccine;-A vaccine administration record is provided to the individual and a copy if filed in the secure employee health file;-The infection preventionist (IP) maintains a tracking worksheet of staff members and their vaccination status;-The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following: -That staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; -That staff were provided education regarding the benefits…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-11 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25, showed the following:-Staff training/education and competencies:-New hire training for nursing staff includes:-Dementia Care: Managing Challenging Behaviors;-Annual Education includes all the new hire training topics plus Corporate Compliance: The Basics for all staff, Overview of the Aging Process and Pressure Ulcer Prevention for all clinical staff. 2. Review of a list of current facility staff, dated 08/05/25, showed the following:-Certified Nurse Aide (CNA) I date of hire: 04/15/09;-CNA/Certified Medication Technician (CMT) C: date of hire 07/19/14;-CNA K date of hire: 12/7/19;-CNA J date of hire: 07/03/23. Review of a list of staff in-service education hours, dated 07/01/24 through 06/30/25, showed the following:-CNA I: 6.50 in-service hours. Dementia training hours blank;-CNA/CMT…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-11 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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 meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the physician's orders and spreadsheet menu. The facility census was 72. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 07/27/25, showed the following:-Severe cognitive impairment;-Diagnoses included vitamin deficiency, -Dependent on staff for eating;-Mechanically altered diet such as pureed food. Review of the resident's Care Plan, revised 02/24/25, showed the following:-The resident receives regular pureed diet;-Staff will need to feed the resident; -Monitor and record percentage of food intake. Review of the resident's Physician Orders dated 03/27/25, showed diet pureed texture, double portions with meals every day. Review of the Diet Spreadsheet Menu, for 8/4/25 (Day 2, Monday) Lunch, showed staff were to serve residents on pureed diets the following items and portion sizes:-One 4-ounce portion of pureed chicken…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-11 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow their antibiotic stewardship policy and consistently track infections and antibiotic use for one resident (Resident #3) in a review of 18 sampled residents. The facility census was 72. Review of the facility's undated policy, Antibiotic Stewardship, showed the following:-The facility will record all antibiotics used in the facility on a resident-to-resident basis (dose, duration, indication);-The facility will alert the attending physician when antibiotics have reached 14 days and obtain new orders. Review of the facility's Surveillance for Infections policy, dated January 2022, showed the following:-The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions (TBP) and other preventative interventions;-The purpose of the surveillance of infections is to identify both individual cases and trends of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility policy review, the facility failed to ensure that food was stored and served according to professional food safety standards. Specifically, the facility failed to date opened food items stored in the reach-in cooler and failed to ensure staff used appropriate hand hygiene and glove use when handling ready-to-eat foods. Findings included: 1. A review of a facility policy titled Food Storage (Dry, Refrigerated, and Frozen), dated 2020, revealed All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The policy revealed Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. An observation in the reach-in cooler on 10/30/2023 at 9:07 AM revealed cooked hamburger meat, lunch meat, and sliced cheese, all stored in plastic bags with no date label. During an interview on 10/30/2023 at 9:24 AM, the Certified Dietary Manager (CDM) stated all items in the refrigerator should be 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-02 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 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 document review and interviews, the facility failed to complete a Minimum Data Set (MDS) at least quarterly for 6 residents (Residents #11, #20, #27, #43, #46, and #50) of 27 sampled residents reviewed for resident assessments. Findings included: A review of the MDS 3.0 RAI (Resident Assessment Instrument) Manual, dated October 2019, in the section titled Chapter 5: Submission and Correction of the MDS Assessments, revealed Assessment Schedule: An OBRA [Omnibus Budget Reconciliation Act] assessment [comprehensive or quarterly] is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. 1. A review of Resident #11's Face Sheet revealed the facility admitted the resident on 02/25/2020. A review of a document titled MDS 3.0 Resident Assessments for Resident #11 revealed the most recent MDS submission to the Centers for Medicare and Medicaid Services (CMS) system with a production accepted status was a quarterly assessment dated [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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-02 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility document review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 14.8%, resulting from 4 errors out of 27 opportunities. Findings included: A review of an undated facility medication technician training course lesson plan titled, Prepare, Administer, Report, and Record Oral Metered Dose Inhaler Medications, revealed, Check medication record/card with label when removing medication from resident's individual compartment in external storage area. Review medication reference materials for any medications with which you are not familiar. Further review revealed, For steroid inhalers, have resident rinse mouth after use to minimize fungus overgrowth and dry mouth. A review of an undated facility medication technician training course lesson plan titled, Prepare, Administer, Report, and Record Oral Medications, revealed, 2. Review and verify medication administration records/cards with physician's order according to facility policy. Check for allergies. Obtain…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure 1 (Resident #36) of 1 resident reviewed for self-administration of medications had been assessed to determine if it was safe for the resident to self-administer an albuterol nebulizer treatment. Findings included: A review of Resident #36's Resident Face Sheet revealed the facility admitted the resident on 05/15/2023 with diagnoses that included dementia and asthma. A review of Resident #36's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 08/23/2023, revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A review of Resident #36's Care Plan, with a reviewed/revised date of 10/31/2023, did not indicate the resident self-administered medication. A review of Resident #36's physician's orders revealed an order dated 05/15/2023 that indicated staff were to administer an albuterol nebulizer treatment twice daily as needed for shortness of breath/wheezing. The order did not indicate the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, facility document review, and review of a Food and Drug Administration (FDA) medication guide, the facility's pharmacy consultant failed to identify and report an irregularity related to the use of a PRN [pro re nata; as needed] antianxiety medication for 1 (Resident #48) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacy consultant failed to identify an order for the use of a PRN antianxiety medication that extended beyond 14 days without a specific duration for the use documented by the resident's physician. Findings included: A review of a Consultant Services Agreement, dated 01/17/2011, and signed by the Consultant Pharmacist on 04/12/2023, revealed the consultant services included, Review the drug regimen of each resident in the FACILITY at least once each month and monitor report in writing outcomes or any irregularity to the FACILITY'S Administrator, Director of Nursing Services and where appropriate, the individual resident's physician. A review of an FDA Valium (diazepam) medication guide…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and review of a blood glucose meter manufacturer's instruction manual, the facility failed to ensure a blood glucose meter was disinfected after use. Specifically, a blood glucose meter was not disinfected after it was used to conduct a finger stick blood glucose test for 1 (Resident #207) of 2 residents who used blood glucose meters stored in the Hall 300/400 treatment cart. Findings included: A review of the Assure Prism Blood Glucose Monitoring System User Instruction Manual, revised in November 2015, revealed, Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. - The meter should be cleaned and disinfected after use on each patient. The Blood Glucose Monitoring System may be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated or discarded when expired; failed to ensure ceiling air vents and equipment were clean and free of an accumulation of debris; failed to ensure the dish machine vent was clean and free of a buildup of debris; failed to maintain fan shrouds inside the walk-in cooler to free of an accumulation of debris; failed to ensure pans were not stacked and stored wet; and failed to ensure trash cans were covered when not in use. The facility census was 88. 1. Review of the facility policy, Food Storage, dated 2010, showed the following: -All containers must be legible and accurately labeled; -Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within three days or discarded. Review of the facility policy, Use of Leftovers, dated 2010, showed the following: -Excess leftovers should be avoided. Leftovers will be properly handled and used; -Leftovers that have not been…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure housekeeping and/or maintenance services were provided to ensure the ceiling vents were clean and good repair. The facility failed to maintain wheelchairs in good repair for four residents (Residents #24, #48, #54 and #81). The facility census was 88. 1. Review of the facility policy Housekeeping and Maintenance Services, dated 5/15/06, showed the following: -Maintain the facility in a manner that enhanced residents ability to engage in daily activities of their choice; -Maintain a safe, comfortable, sanitary, and orderly interior; -Assuresthe environmentt was free of hazards that might contribute to injury or disease; -Provide preventive routine cleaning and maintenance of the room floors, fixtures, windows and furnishings heating and air systems and resident care equipment. 2. Observation on 01/14/20 between 9:03 A.M. and 10:00 A.M. of the Oak View Cottage showed the following: -In room [ROOM NUMBER], the ceiling vent in the bathroom was covered…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foot pedals were in place on wheelchairs during transportation for one resident (Resident #65), in a review of 18 sampled residents and four additional residents, (Resident #46, #60, # 77, and #91). The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding use of wheelchair foot rests. 1. Review of Resident #91's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/19,showed the following: -Diagnosis of Alzheimer's disease -Cognition severely impaired; -Extensive assistance required for transfers; -Walking did not occur; -Totally dependent on staff for wheelchair locomotion; -Devices: wheelchair. Review of resident's care plan updated 2/22/19, showed the following: -Diagnoses included dementia without behavioral disturbances, abnormalities or gait and mobility; -History of falls; -Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-16 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately assess, obtain informed consents, and reassess the safety and effectiveness of cane rail use for three residents (Resident #52, #84, and #85) of 18 sampled residents and five additional residents (Resident # 9, # 50, #60, #65, and #77) who had cane rails in place on their beds. The facility census was 88. Review of the facility's Restraint Policy (Device Decision Policy) undated, showed the following: -Assessment: Before any device can be used the Device Decision Guide must be completed to determine if the device is a restraint, enabler, or safety hazard; -Monitoring: Make observations following the implementation of a device; -Mood-is it improved, behavior, incontinence, skin condition,cognitive function, communication ability, interaction with staff/residents, mobility, history of falls-evaluation by therapies is applicable. Review of the Food and Drug Administration's bed safety guidelines: A Guide to Bed Safety, Bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-16 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to destroy expired medications stored in the medication rooms. The facility also failed to ensure adequate temperature control for the storage of medication in the west wingmedication roomm. Thee facility census was 88. Review of the facility undated policy Disposal of Discontinued and/or Unused Medication showed the following: -All medications to be disposed of must be counted by the pharmacist and licensed nurse or two licensed nurses and record on the drug destruction record; -Any medication that can be returned to the pharmacies would be returned within 30 days; -Medication that could not be returned would be destroyed on the premises within 30 days using a method approved by the US Food and Drug Administration. 1. Observation of Oakview Cottage Medication room on 01/15/20 at 05:05 PM showed the following: -One opened bottle of Milk of Magnesia (laxative), dated 9/23/19, expired 10/19; -One bottle of allergy relief fluticasone (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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for two additional residents (Resident #4 and #193). The facility failed to disinfect a bedside table used for treatment according to acceptable infection control practice for one sampled resident (Resident #5) in a review of 18 residents. The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding providing Activity of Daily Living (ADL) cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 revision, showed the following: -Handwashing is the single most important means of preventing the spread of infections; -Wash hands before and after contact with residents; -Always wash hands for at least 15 seconds…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff provided two additional residents (Resident #193, and #4) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding providing ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the Nurse Assistant In A Long Term Care Facility manual revision 2001, showed the following: For oral hygiene: -Purposes: A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident to prevent infections in mouth, remove food particles and plaque, stimulate circulation of gums, and eliminate bad taste in mouth thus food is more appetizing; -Give oral care before breakfast, after meals, and also at bedtime. For activities of personal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-08-11 · tag F0628 — widespread
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer to four residents (Resident #3, #10, #74 and #78) or the resident representatives, in a sample of four residents reviewed related to discharge or transfer. The facility census was 72. Review of the undated document, Bed Hold Statement and Notice of Emergency Transfers, showed the following:-The facility established and maintains policies and procedures regarding transfer, discharge, and provision of services for all individuals. Upon admission to the facility and again if the resident is transferred to an acute care hospital, the resident (if able) or responsible party is information of the policy on bed holds;-The goal of the facility is to re-admit, after hospitalization, all residents who meet admission guidelines and whose needs can be met with our available services. To…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$77,841 in federal fines across 2 penalties.

  • $69,820 — penalty dated 2025-03-07
  • $8,021 — penalty dated 2024-03-12

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

Who owns this facility

Owner / managerTypeRoleSince
FREEMAN, BYRONIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 07/01/2011
HINSHAW, KELSEYIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 11/12/2012

CMS files one row per role, so the 4 rows in the source record cover these 2 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.

Follow the money — this home’s finances

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

$5.4M
Net patient revenuemost recent cost report
-21.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 40%Medicare 6%Other / private 54%

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 2024. 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

$278per resident / day
operating cost
$8,448per month
≈ monthly operating cost
$229per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265200. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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