Village Care Center INC
810 East Edwards Street, Maryville, MO 64468 · For profit - Corporation · 46 certified beds · (660) 562-3515 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has a citation for mishandling residents’ money or property (F0570)
- 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
- the CMS record shows $12,735 in federal fines (most recent 2026-03-23)
- its payroll- and facility-reported staffing and quality-measure scores sit 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.0% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 6.1% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 12.8% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.1% | 17.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 40.9% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.6% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 11.4% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 90.0% | 63.5% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.48 | 2.11 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.97 | 2.33 | 1.80 | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.13 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 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 6.4–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 46 beds and averages 31.1 residents a day — about 68% occupied, or roughly 15 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.85 hrs/resident/day on weekends vs 3.54 on weekdays — 19% thinner on weekends. RN hours go from 0.70 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2026-03-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect one resident's right to be free from mental and physical abuse when during care, as three staff were providing cares, RN A forcefully pushed the residents wheelchair forward and pulled it back and told the resident something to the effect of Ride'em cowgirl, verbally threatened to shame/humiliate the resident publicly for his/her behavior of taking off his/her clothes in public, when the resident resisted cares and made a biting motion, RN A told the resident babies bite. The resident was reported to be visibly upset and crying and when an aide offered to stay with the resident so the resident could calm down, RN A said no and that the resident needed to go to the dining room so others could see how he/she was acting and they would know what RN A has to deal with. The facility census was 28. On 3/23/26, the Administrator was notified of the past noncompliance which began on 3/3/26. On 3/3/26, facility administration was notified 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.
- Potential for harm · Dcited before2026-06-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — the official record, unedited, may be distressing
Deficiency Text Not Available
- Potential for harm · F2025-03-28 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 35. 1. The facility did not provide a policy for the Dietary Manager qualifications. During an interview on 3/27/25 at 9:42 A.M., Dietary Manager said: -He/She has worked at the facility for ten years; -He/She has been the Dietary Manager for a year; -He/She did not have any dietary manager certifications; -He/She did not know what certifications were required for a dietary manager; -He/She was not currently enrolled in classes for dietary manager certifications; -He/She needed to make a plan with the dietician about enrolling in dietary certification classes. -The facility dietician was contracted to come in once a month. During an interview on 3/28/25 at 2:30 P.M., the Administrator said: -The dietary manager needed to take the dietary management course to obtain the required certifications; -The dietary manager was an interim dietary manager; -He/She had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a record of the dishwasher temperature and chemical tests, failed to cease using dishwasher when temperatures did not meet requirements, failed to keep a daily record of refrigerator temperatures, failed to wash hands in between tasks and in between glove changes, failed to label and date all foods upon receiving and upon opening, failed to ensure kitchen was clean and in good repair, and failed to ensure dishwasher temperature reached minimum temperatures. The facility census was 35. 1. Review of the facility's Food Handling policy, dated 7/2014, showed: -Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized; -All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. The facility's Employee Hygiene and Sanitary Practices policy, dated 10/2017, showed: -Employees 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.
- Potential for harm · E2025-03-28 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 obtained physicians' orders and assess residents for safe administration of medication to be kept at the bedside for two of 12 sampled residents (Resident #19 and #25). The facility census was 35. Review of the facility's policy for Resident Self-Administration of Medication, dated 12/2016, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe to do so; -In addition to general evaluation of decision-making capacity, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; -The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications; -For self-administering residents, the nursing staff will determine who will be responsible (the resident 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.
- Potential for harm · E2025-03-28 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of the 12 sampled residents, (Resident #20 and #25). The facility census was 35. The facility did not provide a policy for ABN's. 1. Review of Resident #20's medical records showed: - Notice of Medicare Non-coverage (NOMNC) CMS - 10123 showed the last date of coverage was [DATE]. The resident signed it on [DATE]; - The facility used an outdated ABN form CMS - R-131 (expired [DATE]) and was signed by the resident on [DATE]. 2. Review of Resident #25's medical records showed: - NOMNC CMS - 10123 showed the last date of coverage was [DATE]. The resident signed it on [DATE]; - The facility used an outdated ABN form CMS -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 dependent residents who were unable to carry out activities of daily living (ADL) received the necessary serviced to maintain good personal hygiene when staff did not provide complete perineal care which affected two of the 12 sampled residents, (Resident #18 and #21). Additionally, the staff failed to provide A.M. care to Resident #18. The facility census was 35. Review of the facility's policy titled, Supporting Activities of Daily Living, revised March 2018 showed: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, rooming and oral care). Review of the facility's policy titled, Perineal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of the 12 sampled residents, (Resident #18 and #21) during the use of a mechanical lift. The facility census was 35. Review of the facility's policy titled, Using a Mechanical Lifting Machine, revised July 2017, showed: - The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; - It is not a substitute for manufacturer's training or instructions; - At least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the undated manufacturer's guidelines for the Direct Supply lift showed: - When lifting and lowering the resident, ensure legs on the adjustable base are in the maximum open position for optimal stability. 1. Review of Resident #18's Significant Change in Status Minimum Data Set, (MDS), a federally mandated assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to keep oxygen tubing off the floor for three residents (Resident #22, #25, and #134), failed to date oxygen tubing for one resident (Resident #134), and failed to fill humidifier bottle with distilled water for one resident (Resident #134), resulting in possible exposure to bacteria and discomfort during oxygen usage. This affected three of 12 sampled residents. The facility census was 35. Review of the facility's Oxygen Administration policy, dated 10/2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as the oxygen flows through; -Periodically recheck water level in humidifying jar; -Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. 1. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-28 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to ensure the bed's dimensions were appropriate for the resident's size, (for resident #134). Additionally the facility failed to obtain physicians orders and care plan the use of bed rails for three residents (Resident #23, #19 and #134). This included three of 12 residents sampled (Residents #23, #19, and #134). The facility census was 35. Review of facility policy, Proper Use of Side Rails, revised 12/2016, showed: -The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medial symptoms; -An assessment will be made to determine if the resident's symptoms, risk of entrapment, and reason for using siderails; -When used for mobility, or transfer, an assessment will include a review of the residents: a) 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.
- Potential for harm · E2025-03-28 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure nurse aides met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 35. Review of the facility's policy titled, Nurse Aide (NA) Qualifications and Training Requirements, revised May, 2019 showed: - Nurse Aides must undergo a state-approved training program; - In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; - Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Ecited before2025-03-28 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent. Facility staff made three medication errors out of 25 opportunities for error, which resulted in a medication error rate of 12%, which affected two of the 12 sampled residents, (Resident # 19 and #27). The facility census was 35. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Drug and biological orders must be recorded on the Physician Order Sheet (POS) in the resident's chart; - All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; - Orders for medications must include: name and strength of the drug; number of doses, start and stop…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff wore the proper personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to workplace hazards that can cause serious injuries or illnesses) which affected one of the 12 sampled residents, (Resident #18), failed to wear gloves when obtaining Resident #19's blood sugar, and failed to clean the port of the insulin pen prior to attaching the needle for Resident #1, #5, and #21. The facility census was 35. Review of the facility's policy titled, Infection Prevention and Control Manual, showed: - Enhanced Barrier Precautions, (EBP), are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes; - EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, record review and interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe and when they did not maintain the only drinking fountain. The facility census was 28. The facility did not provide an environmental policy. 1. Observations beginning on 4/23/24 at 9:24 A.M. showed: -room [ROOM NUMBER] door had scuff marks, the frame had chipped paint with exposed wood; -The exit door's frame was chipped, exposing wooden frame underneath; -The fan heater below the handrail, had a bent metal frame, causing a sharp protrusion of metal at knee/calf height; -Sliding bathroom door of room [ROOM NUMBER] had molding loose on one side, with a 2 inch screw exposed; -Sliding bathroom door of room [ROOM NUMBER] had molding loose on one side, with 2 screws, measuring 1.5 inches and 1 inches, exposed; -room [ROOM NUMBER] door frame had chipped paint with exposed wood; -room [ROOM NUMBER] door…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a complete, accurate and individualized care plan, to address the specific needs for three of the 12 sampled residents (Residents #1, #13 and #22). The facility census was 28. Review of the facility's 2018 policy on Resident's Plan of Care., showed: -Every resident will have a formal plan of care within 48 hours of admission. The care plan team is responsible for periodic review and updating of care plans. -Care plans should be updated when there is a significant change in the resident's condition, with a readmission from the hospital, and at least quarterly. Review of Resident #22's admission MDS (Minimum Data Set) A federally mandated comprehensive assessment completed by facility staff. Completed on 3/26/24., showed: - Not Cognitively Intact - History of behaviors and wondering in the last 7 day look back period. - Limited supervision with activities of daily living. - Independent with mobility and meals. -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure systems and interventions were put in place for one resident to ensure the resident's safety, (Resident #22), This resident had a urinary infection, severely impaired cognition, medication use daily for anxiety as well as narcotic use and had sustained three falls with in a week's time resulting in a hematoma (a collection for blood outside of the broken blood vessel, causing swelling and bruising) to the back of the head, without additional interventions put into place. This effected one resident (Resident #22), of 12 sampled residents. The facility census was 28. Review of the facility policy on Fall Clinical Protocol, dated March of 2018., showed: - The nursing staff will help identify individuals with a history of falls and risk factors for falling. - Those individuals with repeated falls often have an underlying cause. - Staff will identify medical conditions affecting fall risk, complications of falls, and risks for bleeding associated with a fall. - Appropriate interventions will be put into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-11 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interviews, the facility failed to purchase a surety bond with a sufficient amount to ensure the security of all the residents' personal funds held by the facility in the Residents' Trust Fund (RTF) account. The facility census was 27. The facility did not provide a policy regarding personal funds. Review of the facility surety bond, dated 11/24/16, showed a bond amount of $20,000. Review of the RTF account worksheet completed on 3/10/22, for the previous twelve months of reconciled bank statements and petty cash amounts showed the facility was required to maintain a surety bond in the amount of $22,500. During an interview on 3/11/22, at 8:01 A.M., the Business Office Manager (BOM) said: - He/she does not know how much the bond is but, he/she can look it up. - He/she did not know the bond was not high enough. - He/she has only been working at the facility for one month. During an interview on 3/11/22, at 1:25 P.M., the Administrator said he/she did not know prior to today that the bond was not high enough.
- Potential for harm · Ecited before2022-03-11 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow standards of practice by not following and/or obtaining physicians' orders for two of 12 sampled residents (Residents #14 and #26) when staff initiate oxygen (O2) therapy for the residents without a physician order; failed to obtain a physician's order for two residents (Residents #17 and #26) prior to starting hospice services; Failed to administer Flonase nasal spray (used to treat seasonal allergies) correctly for Resident #19, failed to obtain an order for Vick's [NAME] severe nasal spray for Resident #26; and failed to allow fingertips to dry before obtaining blood sugars for Residents #8, #19, and #25. The facility census was 27. Review of the undated facility policy for Physician Drug Orders showed in part: - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. - All drug and biologicals orders shall be written, dated, and signed by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing and nebulizer tubing for four of 12 sampled residents (Resident #13, #20, and #26). The facility census was 27. Review of the facility's undated oxygen and nebulizer protocol policy, showed: - Oxygen and nebulizers will be changed out every two weeks on Friday night shift. - When changing out the oxygen tubing and nebulizer sets, it should be dated when changed out (using a piece of tape to write date on); - Nebulizer must be rinsed out with warm water and let air dry, after each use. - Oxygen filters need to be cleaned every Friday on the night shift. 1. Review of Resident #26's care plan, dated 2/9/22, showed: - The resident had chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing) and was recently in the hospital; - Administer my medication, inhaler and breathing treatments as order by my physician;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-11 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made nine medication errors out of 28 opportunities for error, a medication error rate of 32.14%, which affected four of 12 sampled residents (Resident #8, #17, #22 and #26). The facility census was 27. Review of the facility's undated policy for administration of drugs, showed, in part: - Drugs to be administered are checked against the physician's orders; - Observe the five rights in giving medications: the right resident; the right time; the right medicine; the right dose;and the right method of administration; - Do not return to stock, supplies, excess medicine, or medicine refused by a resident. If a resident refuses the dose, it must be destroyed according to policy; - Read the label three times for each dose of medication prepared. Before removing the container from the medicine cabinet, before preparing the measured amount of the drug and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-11 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure staff discarded expired medications and biologicals stored in the facility emergency kit and in the medication room which affected one of 12 sampled residents (Resident #2); failed to date an opened bottle of lorazepam (used to treat anxiety) for Resident #26; failed to date an opened vial of tuberculin (TB) purified protein derivative (PPD, skin test used to help diagnose tuberculosis infection); failed to date an opened vial of influenza vaccine; failed to ensure staff did not leave medications at bedside for Resident #13 and #22; and failed to ensure there were no loose pills on the floor. The facility census was 27. Review of the facility's undated policy for administration of drugs, showed: - Observe the five rights in giving medications: the right resident; the right time; the right medicine; the right dose; and the right method of administration; - Do not return to stock, supplies, excess medicine, or medicine refused by a resident. If a resident refused the dose, it must be destroyed according…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety, and failed to ensure they stored food properly. The facility census was 27. Review of the facility's undated policy, Procedure for Storing Leftovers, said: - All leftovers should be put into approved container, covered, labeled, and date; - Indicate expiration date for all items. Let cool to appropriate temperature before placing in the refrigerator. - Keep refrigerated items at 40 degrees Fahrenheit or below; cover all foods, and store meats on the bottom shelf. - Employ safe food handling and infection control practices at all times to avoid cross contamination. 1. Observation on 3/8/22 beginning at 9:11 A.M. showed the following: - Two frozen meat packages not labeled or dated; - One plastic sacks containing frozen biscuits; - One frozen bag of chopped ham not labeled or dated; - One plastic sack containing mozzarella sticks; - One plastic sack containing frozen red potatoes; - One plastic sack containing frozen rolls.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when administering medications and did not follow the facility's policy, which affected one of 12 sampled residents (Resident #21). Staff failed to clean the glucometer (machine that checks the level of glucose in the blood) appropriately which affected Residents #8, #22, and #25 and failed to clean the insulin port before attaching the needle, which affected Residents #8, #22, and #25. Staff failed to wash their hands between dirty and clean tasks for Residents #6, #10, #13, and #21. The facility census was 27. Review of the facility's infection prevention and control policy, updated 3/16/20, showed, in part: - The primary purpose of the facility's infection prevention and control policies and procedures are to establish guidelines to follow to provide a safe, sanitary and comfortable environment and 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.
- Potential for harm · D2022-03-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 clarify the status of two of 12 sampled residents (Residents #20 and #26) advanced directive and code status. The facility census was 27. Review of the facility policy dated [DATE] Advanced Directive Policy showed in part: - Statement: To ensure everyone has the information necessary to make an informed decision concerning their medical care, the right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives. - Should the resident or family member indicate that an advanced directive exists about his or her care treatment, the facility will require that a copy of such directives be included in the medical record. - Social Services representative is to document in the medical record wether or not the individual has executed an advanced directive. - Changes or revocations of a directive must be submitted to the facility, in writing. The facility may require new documents if the changes are extensive. The care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform one of 12 sampled residents (Resident #26) and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital. The facility census was 27. Review of the facility's bed hold policy dated 1/26/15, showed: - The facility will notify all residents and/or their representative of the bed hold guidelines upon admission in writing. - At the time of transfer to the hospital, at the time of non-covered therapeutic leave and notified verbally of one of these changes by the facility or resident and/or representative will start the bed hold guidelines. 1. Review of Resident #26's significant change in condition Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 2/24/22, showed: - A brief interview for mental status (BIMS) score of 11 which indicated moderate cognitive impairment. - Required two staff members' assistance with activities of daily living. -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for two of 12 sampled residents (Resident #13 and #26).The facility census was 27. Review of the facility policy, dated February, 2018, Resident Plan of Care showed in part: - Policy Statement: To ensure staff follows a plan of care on each resident admitted . - The care planning team is responsible for maintaining care plans on a current status. The care planning team is responsible for periodic review and updating care plans: a. When there has been a significant change in the resident's condition; b. When the resident has been readmitted to the facility from a hospital stay; and c. At least quarterly. 1. Review of Resident #26's significant change in status Minimum Data Set (MDS), a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected two of 12 sampled residents (Resident #6 and #13) and failed to ensure showers and shaving were completed for Resident #13. The facility census was 27. Review of the facility's perineal care skills check, dated 5/2/17, showed, in part: - It is the policy of the facility to conduct perineal care in order to accomplish the following objectives: to prevent infections, prevent inflammation and/or facilitate healing of reddened perineal area and to enhance the resident's comfort; - Wash the front of the resident first; begin by washing off the lower abdomen, then the tops of the hip and thigh regions; - Men - cleanse the skin folds by using circular motion. Gently wash the skin fold by lifting it and cleaning from the tip…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 12 sampled residents (Resident #6 and #10) during a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) transfer and during the use of a mechanical lift transfer for Resident #21. The facility census was 27. Review of the facility's policy for gait belts, revised 3/20/14, showed, in part; - The purpose is to provide resident safety and protection during the transfer and upon ambulation; to prevent dislocations of the shoulder; and aid in controlling balance; - Apply the gait belt around the resident, over clothing and never next to bare skin; - The belt should be at mid-waist and snug enough to not slide up the resident's body, but not tight enough to cause pain; - If the resident is a female, be sure the belt is not over the breasts; - Assist the resident at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to follow the facility's skills check for insulin administration when staff failed to prime the insulin pens with two units prior to administering insulin to two of 12 sampled residents, (Resident #8 and #22). The facility census was 27. Review of the facility's skills check for accucheck and insulin administration, dated 4/15/19, showed, in part: - Prime insulin pen; dial up two units and dispense. 1. Review of Resident #8's physician order sheet (POS) dated March 2022, showed: - An order for Levemir insulin, 40 units twice daily for diabetes mellitus; - An order for Novolog insulin per sliding scale before meals for diabetes mellitus, blood sugar 201 - 250, give 17 units. Review of Resident #25's POS, dated March 2022, showed: - An order for Levemir insulin, 58 units at bedtime for diabetes mellitus; - An order for Novolog insulin, 17 units with meals for diabetes mellitus. Observation on 3/11/22 at 7:16 A.M., showed for Resident #8: - Registered Nurse (RN) A removed two insulin pens from the drawer 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$12,735 in federal fines across 1 penalty.
- $12,735 — penalty dated 2026-03-23
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.
Part of a chain
This home belongs to OSBYCORP — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.0 | +1.0 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 1 home this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OSBY, EDMUND | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 100% | since 01/01/1995 |
| OSBY SERTTERH, JACQUELINE | Individual | CORPORATE OFFICER | — | since 07/15/2014 |
| OSBY, CHARLENE | Individual | CORPORATE OFFICER | — | since 01/01/1997 |
| OSBY, JENNIFER | Individual | CORPORATE OFFICER | — | since 01/01/2015 |
| ALLEN, ROGER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/26/2023 |
| BOMAR, SALLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2000 |
| CONSTANT, KATIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/06/2023 |
| HUNTSMAN, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/21/2024 |
| PERCELL, MCKENZIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/23/2023 |
| SCOTT, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/08/2014 |
| BCG HOLDINGS INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| BLUE STONE THERAPY INC | Organization | ADP OF THE SNF | — | since 04/30/2003 |
| BRIGHTON CONSULTING GROUP LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL BCG LLC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| CATTAIL CONSULTING LLC | Organization | ADP OF THE SNF | — | since 09/30/2022 |
| CATTAIL INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| ECSI INC | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| IOWA HEALTH CARE ASSOCIATION | Organization | ADP OF THE SNF | — | since 10/01/2024 |
| NUTRITION ANALYST, LLC | Organization | ADP OF THE SNF | — | since 12/31/2020 |
| OSBYCORP INC | Organization | ADP OF THE SNF | — | since 01/12/2021 |
| WIPFLI LLP | Organization | ADP OF THE SNF | — | since 08/18/2021 |
CMS files one row per role, so the 24 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
11 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $108K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265643. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-28, 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 →
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