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Living Center, The

2506 Linden Tree Parkway, Marshall, MO 65340 · Non profit - Corporation · 99 certified beds · (660) 886-9676 Medicare & Medicaid certified

Call the home — (660) 886-9676 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jul 2024Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2303 S Highway 65, Ste A · (660) 831-1175 · Call to confirm hours
Pharmacy
895 W College St · (660) 831-5220 · Call to confirm hours
Grocery
Aldi1.1 mi
975 W College St · (855) 955-2534 · Call to confirm hours
Park
(660) 886-7911 · Typically dawn to dusk
Place of worship
1823 S Miami Ave · (660) 886-9772

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 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 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 increased8.6%18.1%15.4%better
Long-stay residents who lose too much weight5.3%5.3%5.4%typical
Long-stay residents with a catheter left in their bladder1.6%1.1%0.9%worse
Long-stay residents with a urinary tract infection6.6%2.3%2.0%worse
Long-stay residents with depressive symptoms0.0%18.5%6.5%check this — see note marked star 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 injury3.9%4.1%3.3%worse
Long-stay residents whose ability to walk worsened5.0%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.8%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine93.8%90.9%95.3%typical
Long-stay residents with pressure ulcers3.9%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control16.4%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table29.3%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine57.1%63.5%79.4%worse
Short-stay residents rehospitalized after admission35.2%26.0%22.6%worse
Short-stay residents with an outpatient ER visit14.8%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.312.111.67better
Long-stay outpatient ER visits per 1,000 resident days2.762.331.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

50.4% 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 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.4%U.S. median 51.5%
Got home and stayed home
13.2%U.S. median 10.7%
Went back to hospital
29.1%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 29.1% 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 55 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF50.4%CMS range 44.1–60.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.2%CMS range 9.9–17.210.7%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 discharge29.1%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 discharge30.9%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 discharge27.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified74.6%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization7.2%CMS range 4.0–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 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

0.47
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.38
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.19
RN hoursweekends
35.8%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 67.1 residents a day — about 68% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 4.08 on weekdays — 18% thinner on weekends. RN hours go from 0.58 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

4
deficiencies at the latest standard inspection (2024-07-18)
11
at the previous standard inspection (2023-02-09)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-07-09 · 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 interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1), in a review of seven sampled residents. Staff failed to monitor Resident #1, who was taken outside by staff, at approximately 1:27 P.M. to 3:30 P.M. The resident sat in the courtyard under the gazebo and self-propelled him/herself in the courtyard with temperatures between 78 degrees Fahrenheit (F) and 86 degrees F. When discovered by staff at approximately 3:30 P.M., the resident had wheeled himself/herself out from under the gazebo, had his/her back wheel of the wheelchair off of the sidewalk, had taken his/her shoes and socks off and had a red face and his/her skin was hot to touch. The resident was assessed and noted to have an elevated temperature of 101.3 degrees F (normal temperature is between 97.8 degrees F and 99.1 degrees F), had lethargy (sluggish, drowsy and lack of energy), was dry heaving and leaning to the right with reddened skin. The facility census was 64. The administrator was notified of the past noncompliance on 07/09/25 which occurred on…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2023-02-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to routinely assess pain, administer pain medications timely after pain was identified, notify the physician of unresolved pain, administer pain medications in anticipation of activities that cause pain, and re-evaluate if medications administered were effective for one resident (Resident #1) who was distressed, and rated his/her pain a eight on a zero to ten scale with ten being the worst pain possible. The resident said he/she was hurting too bad to get out of bed for lunch. The resident had possible fractures that had been identified and had not been treated, and pressure ulcers to his/her heels and coccyx. The facility census was 67. Review of the facility's policy on Pain Assessment and Management, revised on March 2015, showed the following: -The purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address 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 before2024-07-18 · 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 two ice machines were free of a buildup of debris, failed to properly store an ice scoop in the serving kitchen, and failed to ensure the refreshment area ice machine was equipped with an adequate air gap. The facility also failed to safely store food items in two refrigerators in the serving kitchen. The facility census was 69. 1. Review of the facility policy, Infection Prevention and Control, Nutritional Services, dated May 2015, showed the following guidance for the Ice Machine in the Food Server Area: -Run the scoop through the dish machine and air dry daily. Store them in clean Ziploc bag; -Wipe the exterior of the machine with warm, sudsy water, rinse and sanitize weekly; -The vendor is responsible for cleaning ice machine quarterly; -Check the interior of the ice cabinet, lid and gaskets for any signs of mold or mildew between monthly vendor visits. If they're visible, follow the cleaning procedures. Observation on 07/15/24 at 10:33 A.M. in the dining room serving kitchen, showed an ice machine…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · 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

    Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for one resident (Resident #34), of 20 sampled residents and four additional residents (Resident #13, #38, #48 and #54). The facility census was 69. 1. During an interview on 07/18/24 at 3:59 P.M., Registered Nurse (RN) A said the facility followed the Resident Assessment Instrument (RAI) manual to guide completion of all of the MDS assessments and the facility did not have a specific policy related to MDS completion. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2023, showed the following: -The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation for continued use of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Resident #12, #34 and #56), and failed to complete a 14-day review for the PRN (as-needed) use of a benzodiazepine (a drug that produces sedation and hypnosis) for three residents (Resident #42, #57 and #63) in a review of 20 sampled residents. The facility census was 69. Review of the facility's policy, Antipsychotic Medication Use, dated (revised) December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but…

    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 · D2024-07-18 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 #1), in a review of 20 sampled residents, remained free from misappropriation of property when Certified Nurse Aide (CNA) F took the resident's cellular phone and made charges of approximately $200 to the resident's online shopping account without the resident's knowledge. The facility census was 69. On 7/3/24 at 4:08 P.M., the administrator was notified of the past noncompliance which occurred on 6/25/24. On 6/25/24, the administrator became aware of the violation of misappropriation of the resident's phone and charges made to the resident's online shopping account by CNA F. Upon discovery, the facility canceled the contract with CNA F through the contracting company, conducted an investigation, and notified appropriate parties. Staff reviewed the facility misappropriation policy, and all facility staff were educated on the facility misappropriation policy. CNA F was terminated. The deficiency was corrected on 6/26/24.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2023-09-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately, but no later than two hours after the allegation was made, for one resident (Resident #2), in a review of five sampled residents. Resident #2 reported staff threw him/her into the sink while assisting the resident in the bathroom on 9/17/23. The facility failed to report the allegation of abuse to the state survey agency. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -The residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility prohibited mistreatment, neglect or abuse of the residents; -The facility must ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator and to other officials immediately, but no later than 2 hours after the allegation was made 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect residents from potential abuse after one resident (Resident #2), in a review of five sampled residents, reported Certified Nurse Assistant (CNA) A and CNA B threw him/her into the sink while assisting the resident in the bathroom. The facility allowed the staff to continue to work the remainder of their shift on 9/17/23 and the following night shift. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish, or deprivation by and individual, including a caretaker of goods or services that were necessary to attain or maintain physical, mental and psychological well-being; -Physical abuse was hitting, slapping, pinching, kicking, etc. It also included controlling behavior through corporal punishment; -The facility must ensure all alleged violations involving mistreatment, neglect or abuse, including injuries…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-21 · 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 interview and record review, the facility failed to identify and communicate to staff effective interventions to prevent falls for one resident (Resident #2), who was admitted with left sided weakness from stroke, in a review of six sampled residents. The resident rolled out of bed on the left side when trying to obtain items that were out of reach. The facility staff also failed to use appropriate transfer techniques for the resident, who staff assessed as high risk for falls, when they failed to transfer the resident using a gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning) as directed in the resident's plan of care. The facility census was 67. Review of the facility's undated policy, How to Transfer an Individual Using a Gait Belt, showed the purpose was to provide safety and protection from possible injury during transfers and ambulation. Apply the belt while the individual was in a comfortable sitting position. If the individual had a weak side, make sure his/her stronger side was facing the destination such…

    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 · D2023-09-21 · 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

    Based on interview and record review, the facility failed to provide appropriate care and services to maintain the highest practical well-being for one resident (Resident #1) with a diagnosis of dementia, in a review of five sampled residents. The facility identified the resident did not like and became upset when staff of the opposite sex provided his/her care. The facility failed to ensure the direct care staff who provided care for the resident on 9/17/23 were of the same sex as the resident, and failed to follow the resident's care plan to approach the resident at another time when the resident was combative or refused care. During incontinence care on 9/17/23, the resident became upset, combative, swatting his/her arms, and resisted care. Staff continued to provide care for the resident, and the resident sustained a skin tear. The facility census was 67. Review of the facility policy, Dementia Clinical Protocol, dated March 2015, showed the following: -The facility would review the past and current physical, functional, and psychosocial status of each individual with dementia…

    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 before2023-02-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure proper handwashing techniques during meal service. The facility census was 76. Observation on 02/06/23 during the noon meal service showed the following: -At 12:03 P.M., Dietary Aide A wore gloves and touched trays, plates, meal tickets, and ice cream cups, and without removing his/her gloves touched the potatoes on a resident's plate with his/her gloved hand; -At 12:10 P.M., Dietary Aide A touched plates and the microwave, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; -At 12:17 P.M., Dietary Aide A touched plates, trays, and utensils, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; -At 12:27 P.M., Dietary Aide A touched plates, the plate warmer, and trays, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on the resident's plate. He/She then touched utensils, menu slips, and trays, and without removing his/her…

    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 · E2023-02-09 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of 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 reasonable accommodations of needs for three residents (Residents #9, #17 and #53), in a review of 19 sampled residents, when their call lights were not accessible for use. The facility census was 76. The facility did not have a policy on call light accessibility. 1. Review of Resident #9's face sheet showed the resident's diagnoses included dementia and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as a stroke). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/22, showed the following: -Moderately impaired cognition; -Total dependence on two staff for transfers. Review of the resident's care plan, revised on 1/23/23, showed the following: -Provide him/her with dependent help of two staff for transfers with a hoyer lift (a mechanical lift used with a sling 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
Show the remaining 17 citations
  • Potential for harm · Ecited before2023-02-09 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders and professional standards of care for two residents (Residents #5 and #38), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy Physician/Provider Orders, revised 5/2018, showed all physician orders should be executed in a timely manner. Review of the facility policy, Administering Medications through a Metered Dose Inhaler, reviewed 10/2010, showed allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 1. Review of Resident #38's face sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD; a group of lung disease that block air flow and make it difficult to breathe). Review of the resident's February 2023 physician order sheet showed the following: -Symbicort inhaler (an inhaled steroid medication used to treated COPD), inhale one puff twice a day;…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 the necessary care and services to maintain good personal hygiene for eight residents (Residents #9, #17, #22, #26, #27, #37, #51, and #53), who required assistance to perform their activities of daily living (ADLs), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy, Care of Fingernails/Toenails, revised 10/2010, showed the following: -The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection; -General Guidelines: 1. Nail care includes daily cleaning and regular trimming; 2. Proper nail care can aid in the prevention of skin problems around the nail bed; 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin; -Documentation: The following information should…

    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 · Ecited before2023-02-09 · 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 resident safety for three residents (Residents #5, #14 and #53) in a review of 19 sampled residents. Staff failed to use a gait belt while assisting two residents (Resident #5 and #14), and lifted the residents under both arms and pulled up on the back of the residents' pants during the transfer. Staff also failed to ensure two residents (Residents #14 and #53) had foot pedals on their wheelchairs prior to staff propelling the residents in the facility. The facility census was 76. Review of the facility policy How to Transfer an Individual Using a Gait Belt dated 2010 showed the following: The purpose was to provide safety and protection from possible injury during transfer and ambulation; 3. Apply the gait belt while the individual is in a comfortable sitting position. If the individual is lying in bed and has poor sitting balance, apply the gait belt while they are lying down; 4. Make sure the belt is applied tightly enough 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-09 · 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 obtain informed consent and educate residents and their responsible parties on the risk of bedrail use and failed to document attempted alternatives prior to installing the bed rails for seven residents (Resident #57, #27, #25, #22, #17, #4 and #7) and failed to assess one resident (Resident #7) in a review of 19 sampled residents, for bed rails and risk of entrapment. The facility census was 76. Review of the facility policy, Siderails and Beds - Safety, updated 5/22/22, showed the following: -Beds, bed frames, siderails and mattresses shall be routinely inspected by the engineering department for possible areas of entrapment; -Resident's individualized needs for siderail use shall be determined by a multidisciplinary team, and shall include, but not limited to, an assessment of: psychiatric diagnosis, medical needs, comfort, nighttime and sleeping habits, and freedom of movement; -Siderails shall not routinely be placed in the up…

    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 · E2023-02-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility census was 76. Review of the noon meal menu for 02/06/23 showed meal items included chicken fried chicken, carrots and green beans. Observation on 02/06/23 of the noon meal showed the following: -At 12:03 P.M., staff served first the first resident meal tray from the steam table in the serving area; -At 12:37 P.M., staff served the last resident meal tray; -At 12:40 P.M., the test tray was received. The temperature of the chicken fried chicken was 98 degrees Fahrenheit, the grilled chicken was 100 degrees Fahrenheit, the carrots were 105 degrees Fahrenheit, and the green beans were 108 degrees Fahrenheit. The food was cool to taste. During an interview on 02/06/23 at 3:27 P.M., Resident #27 said the food was sometimes cold when he/she gets his/her tray. During the resident group meeting on 2/7/23 at 11:20 A.M., Resident #35 said breakfast was cold a lot of the time. He/She ate breakfast in his/her room. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-09 · 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 before or after applying gloves or when in direct resident contact, failed to change gloves during personal care and wound care, and failed to ensure proper handling of soiled linens, clothing and incontinence care items when indicated by professional standards of practice for six residents (Resident #5, #9, #14, #53, #57 and #420), in a review of 19 residents. The facility census was 76. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-09 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility staff failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for seven residents (Resident #4, #7, #17, #22, #25, #27, and #57), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy, Siderails and Beds - Safety, updated 5/22/22, showed the following: -Beds, bed frames, siderails and mattresses shall be routinely inspected by the engineering department for possible areas of entrapment; -Inspection includes assessment of the following zones: 1. Within the rail; 2. Between the top of the compressed mattress and the bottom of the rails, between the rail supports; 3. Between the rail and the mattress; 4. Between the top of the compressed mattress and the bottom of the rails, at the end of the rail; 5. Between the split bed rails; 6. Between the end of the rail and the side edges of the head or foot board; 7. Between the head or foot board and the mattress end; -There shall be no gaps wide…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #9), in a review of 19 sampled residents, received oxygen therapy consistent with professional standards of practice. The facility census was 76. During interview on 2/24/22, at 11:10 A.M., the Director of Nursing said the facility did not have an oxygen administration and monitoring of oxygen therapy policy. 1. Review of Resident #9's face sheet showed the following: -admission to the facility on 1/26/22; -Diagnoses included dementia without behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning without aggression), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as a stroke), atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood). Review of the resident's quarterly Minimum Data Set (MDS), a federally…

    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 before2019-07-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain holding temperatures of pureed food items at 140 degrees Fahrenheit (F) and failed to maintain an ice machine air gap between the drain and the floor in the skilled facility. The facility census was 57. 1. During an interview on 7/22/19 at 11:04 A.M. Dietary Staff P said there were four residents in the long term care facility that were on a pureed diet. Pureed items came already molded/frozen and were cooked in the oven prior to serving. Observation on 7/22/19 at 11:33 A.M. showed Dietary Staff P temped the pureed food items for the nursing home residents and showed the following temperatures: -Pureed chicken and vegetable bake measured 169 degrees F; -Pureed corn measured 179 degrees F; -Pureed broccoli measured 179 degrees F; -Staff placed these items in an insulated rolling cart and left the door open as additional items were loaded inside. Observation on 7/22/19 at 11:38 A.M. showed Dietary Staff Q closed the cart door and pushed the cart to the long term facility kitchen. Observation on 7/22/19 at 11:40 A.M.…

    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 before2019-07-25 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided services that met professional standards of quality for medication administration for two residents (Resident #14 and #31) in a review of 15 sampled residents and when staff provided treatments without a physician's order for one sampled resident (Resident #25) and one additional resident (Resident #103). The facility census was 57. 1. Review of the facility policy, titled, Administering Medications, revised 01/01, showed the following: -Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders; -Except for single unit dose packets and IV's, only the individual preparing the resident's medication may administer it; -Medications may not be prepared in advance and must be administered within one (I) hour of their prescribed time. (Note: Before and/or after meal orders must be administered as ordered.); -The individual administering the medication must…

    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 · E2019-07-25 · 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 observation, interview, and record review, the facility failed to administer medications with an error rate of less than 5 percent (%) for two residents (Residents #14 and #31) in a review of 15 sampled residents. There were 39 opportunities for errors with two errors, which resulted in an error rate of 5.13%. The facility census was 57. 1. Review of the facility policy titled, Administering Medications, revised 01/01, showed the following: -Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director; -Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders; -The individual administering the medication must ensure that the right medication, the right dosage, the right time and the right method of administration are verified before the medication is administered (e.g., review of drug label, physician orders, etc.). 2. Review of Resident #14's care plan, dated 5/8/19, showed the resident had a history of loose stools. Review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-07-25 · 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 nursing staff washed their hands and changed gloves when indicated by professional practices during eye drop administration and topical antifungal treatment to ensure the antifungal cream's tube tip was free of contamination for one resident (Resident #31) in a review of 15 sampled residents. Facility staff also failed to follow infection control practices while performing blood glucose monitoring for one sampled resident (Resident #45) and five additional residents (Resident #6, #1, #3, #11 and #52) when staff failed to appropriately sanitize the glucometer machine (machine that tests a droplet of blood for the amount of sugar it contains) after use. The facility census was 57. 1. Review of the facility policy titled, Administering Topical Medications, revised October 2010, showed the following for paste, cream, ointment, or lotion applications: -Open the container and place the tube upside down on the table surface; -Apply clean…

    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 · E2019-07-25 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and vaccinate eligible residents with the pneumococcal vaccines as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines, for five residents (Residents #14, #30, #31, #36 and #46), in a review of 15 sampled residents and one additional resident (Resident #27). Further review showed there was no documentation the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. The facility census was 57. 1. Review of the facility policy titled, Pneumococcal Vaccine, revised October 2014, showed the following: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless…

    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 · D2019-07-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 notify one resident's (Resident #25's) physician, in a review of 15 sampled residents, when the resident had a change in condition. The facility census was 57. 1. Review of the facility policy, titled, Physician Notification Policy and Procedure, revised May 24, 2011, showed the following: -Our facility shall promptly notify the resident's attending physician or practitioner of any clinical problems, changes in laboratory values, or changes in vital signs according to the guidelines laid out in the policy; -The nurse supervisor/charge nurse will notify the resident's attending physician or on-call practitioner when there has been: -A significant change in the resident's physical/emotional/mental condition; -Any contacts with the physician or practitioner must be documented in the resident's record as well including the date, time, assessment date reported, response of the physician, and the nurse making the call. If any orders are given they must be documented following the procedure for transcribing…

    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 · D2019-07-25 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 systematic process for evaluating if a recliner chair, implemented as an intervention to prevent falls for one resident (Resident #203), in a review of 15 sampled residents, was a restraint. The resident could not easily or intentionally exit or change his/her position from fully reclined to upright when in the chair. The facility also failed to identify the medical symptom the recliner was being used to treat, and failed to provide care planning and assessments on an ongoing basis to address the recliner and it's restraining properties. The facility census was 57. 1. During interview on 7/24/19 at 3:00 P.M. the Director of Nursing (DON) said the facility did not have a policy for restraints. 2. Record review of Primaris website regarding restraints, showed the following: -The Centers for Medicare and Medicaid Services (CMS) has recognized the danger restraints pose to residents and has initiated national efforts to reduce the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record record the facility failed to provide appropriate care, treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for two residents (Resident #45 and Resident #4 ) with an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) of 15 sampled residents. The facility identified three residents with indwelling catheters. The facility census was 57. 1. Review of the facility policy Urinary Catheter: Indwelling Catheter Care dated May 2019 showed the following: -When the indwelling catheter is no longer needed, remove it as soon as possible because of the risk for catheter-associated urinary tract infection; -Secure the drainage bag and tubing below the level of the bladder; -The policy did not address keeping catheter tubing off the floor. 2. Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, showed the following: -The bladder is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to show adequate indications for use of an antipsychotic medication (a class of medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia and bipolar disorder) and hypnotic medication (commonly known as sleeping pills, are a class of psychoactive drugs whose primary function is to induce sleep and to be used in the treatment of insomnia (sleeplessness), or for surgical anesthesia) and monitor psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) use for one resident (Resident #203) in a review of 15 sampled residents. The facility census was 57. 1. Review of the undated facility policy Gradual Dose Reduction showed the following: Policy: Physicians will use psychotropic medications appropriately working with the…

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

    Pharmacy Service 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
FITZGIBBON HEALTH SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/06/1995
HAUG, DARINIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 05/01/2015
LITTRELL, ANGELAIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/02/2014
JOHN FITZGIBBON MEMORIAL HOSPITAL INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/05/1995
HEARTING, DELMAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2022

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$5.4M
Net patient revenuemost recent cost report
-20.3%
Operating marginrevenue minus expenses
$451K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 6%Other / private 41%

This home reported $451K 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 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

$277per resident / day
operating cost
$8,406per month
≈ monthly operating cost
$230per 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 265688. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-18, 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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