Cotton Point Living Center
609 South Railroad Street, Matthews, MO 63867 · For profit - Individual · 98 certified beds · (573) 471-7861 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jul 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0567, F0568, F0569)
- 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 $14,069 in federal fines (most recent 2025-07-31)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
- about 32% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 | 27.3% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.0% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.6% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.2% | 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 | 7.3% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 34.8% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 42.3% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 81.8% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.9% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 43.4% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 10.0% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 21.4% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.7% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.6% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.69 | 2.11 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.60 | 2.33 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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
| 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 | 11.7%CMS range 8.1–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 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 | 92.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.9% | 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 | 3.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 5.1–14.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 98 beds and averages 46.9 residents a day — about 48% occupied, or roughly 51 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.02 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 4.35 on weekdays — 19% thinner on weekends. RN hours go from 0.44 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2025-07-31 · 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 observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse on 07/23/25 when, as staff escorted the residents outside to smoke, Resident #2 made physical contact pushing Resident #1 down to the floor. Resident #1 was sent to the emergency room and diagnosed with a fractured hip that required surgical repair. The facility census was 60.The Administrator was notified on 07/31/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 07/23/25. Upon notification, the facility administration immediately started an investigation, notified the police department and Department of Health and Senior Services of the incident, and in-serviced all staff on the facility's policy and procedures for abuse and neglect. The IJ was corrected on 07/24/25. Review of the facility's policy titled, Abuse Prevention Program, undated, showed:The facility will not tolerate verbal, sexual, physical, or mental abuse, corporal punishment, 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 · Ecited before2026-05-14 · 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, interview and record review, the facility failed to maintain sanitary conditions for ice intended for resident consumption. The facility failed to ensure the ice machine drain line maintained a required air gap (empty space that ensures dirty sewer water can never flow backward into the ice machine and contaminate the ice) to prevent potential contamination, failed to maintain sanitary conditions surrounding the ice machine, and failed to prevent contamination of communal ice during resident use. These deficient practices had the potential to affect all residents who consumed ice from the facility ice machine. The facility census was 47.Review of the facility's policy titled, Sanitization, revised November 2022, showed:- Ice machines and ice storage containers are drained, cleaned, and sanitized per manufacturer's instructions;- Ice chest and coolers used to store and transport ice are cleaned regularly, especially prior to use or when contaminated or visibly soiled;- Did not address the air gap required for the ice machine. 1. Observations on 05/11/26 at 10:32…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide restorative services for one resident (Resident #9) out of two sampled residents and one resident (Resident #17) outside the sample. The facility census was 47.Review of the facility's policy titled, Restorative Nursing, revised July 2017, showed:- Residents will receive restorative nursing care as needed to help promote optimal safety and independence;- Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care;- Restorative goals may include, but are not limited to supporting and assisting the residents in:a) Adjusting or adapting to changing abilities;b) Developing, maintaining or strengthening his/her physiological and psychological resources;c) Maintaining his/her dignity, independence and self-esteem; andd) Participating in the development and implementation of his/her plan of care. 1. Review of Resident #9'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.
- Potential for harm · Dcited before2026-05-14 · 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 monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals, and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents, failed to document an assessment after a fall, to notify the provider and the on-call nurse after a fall, and to update the care plan with new interventions to prevent additional falls for one resident (Resident #49) out of two sampled residents. The facility census was 47.Review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, showed:- Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling;- A fall is unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming force (a resident pushes another resident). An episode where 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 · D2026-05-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 maintain a medication error rate of five percent (%) or less. There were four errors out of 27 opportunities for errors, resulting in an error rate of 14.81%. This affected three residents (Residents #9, #30, and #36) out of five sampled residents. The facility census was 47.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed:- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #9's medical record showed:- admitted on [DATE];- Diagnoses 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 · D2026-05-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #30 and #36) were free from significant medication errors when staff did not administer medications as ordered by the physician and did not document the correct blood sugar reading. The facility census was 47.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed:- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #30's medical record showed:- admitted on [DATE];- Diagnoses of hyperlipidemia (high cholesterol),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three residents (Residents #9, #13, and #15) out of five sampled residents received the influenza (a highly contagious respiratory illness) immunization. The facility census was 47.Review of the facility's policy titled, Influenza, Prevention and Control of Seasonal, dated August 2014, showed:- The Infection Preventionist (IP) will promote and administer the seasonal influenza vaccine;- Unless contraindicated, all residents and staff will be offered the vaccine. 1. Review of Resident #9's medical record showed:- admitted on [DATE];- Diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease) and Alzheimer's disease (a progressive and irreversible brain disorder);- No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine;- No documentation of the consent or refusal for the influenza vaccine;- No documentation the resident received 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 · D2025-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 54. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. Observations on 03/04/25 at 10:21 A.M., and 03/05/25 at 8:15 A.M., of room [ROOM NUMBER] showed: - A buildup of dust and dirt on the air filter inside the air conditioner unit; - Several long dark markings on the wall near the light switch by the door; - Two areas of exposed sheetrock and peeled paint on the wall near the recliner;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) for one employee (Employee I) prior to hire and to check the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) periodically for six employees (Employees G, I, J, K, L, and M) out of ten sampled employees. The facility census was 54. Review of the facility's policy titled, Employee Disqualification List (EDL), dated February 2022, showed: - At the time of consideration of employment, the designated employee shall access the EDL website and check the EDL; - The designated employee will review the EDL list on the EDL website to make certain the name of the employee has not been placed on the the EDL since the initial checking requirement; - The annual and quarterly information is found on the same website as the individual information; - The annual list is updated each January. - Each quarter, names are added and deleted; - 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 · D2025-03-07 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments, a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for two residents (Residents #37 and #40) out of 14 sampled residents and two residents (Residents #38 and #42) outside the sample. The facility's census was 54. Review of the facility's policy titled, Resident Assessments, dated October 2023 showed: - A comprehensive assessment of each resident is completed at intervals designated by Omnibus Budget Reconciliation Act (OBRA) regulations and Protective Payment System (PPS) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. - OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and Medicaid certified nursing homes. OBRA assessments include: a. admission assessment; b. Quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for two residents (Residents #17 and #41) out of 14 sampled residents. The facility's census was 54. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated October 2023, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; - Submission of MDS records to the to the Internet Quality Improvement Evaluation System (iQIES) is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of 15 months from the date submitted. 1. Review of Resident #17's MDS record…
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 · D2025-03-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to include an admitting diagnosis of post traumatic stress disorder (PTSD - psychological distress following a traumatic event) with specific interventions on the baseline care plan upon admission for one resident (Resident #158) out of two sampled residents. The facility census was 54. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident; - The baseline care plan is used until the staff can conduct the comprehensive assessment and develop interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission); - The baseline care plan is updated as needed to meet 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 · D2025-03-07 · 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 — 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 and/or follow physician's orders for three residents (Residents #15, #37 and #158) out of five sampled residents and one resident (Resident #2) outside the sample. The facility census was 54. Review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed: - Orders for medication 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; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; - Drugs and biological orders shall be recorded on the physician's order sheet (POS) in the resident's chart; - Such orders are reviewed by the pharmacy consultant on a monthly basis. 1. Review of Resident #2's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement, monitor and modify interventions to maintain acceptable parameters of nutritional status for two residents (Residents #19 and #40) out of four sampled residents. The facility census was 54. Review of the facility's policy titled, Weight Assessment and Intervention, dated March 2022 showed: - Resident weights are monitored for undesirable or unintended weight loss or gain; - Residents are weighed upon admission and at intervals established by the interdisciplinary team; - Any weight change of 5% or more since the last weigh assessment is retaken the next day for confirmation; - Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. one month - 5% weight loss is significant; greater than 5% is severe; b. three months - 7.5%…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three medication carts. This practice had the potential to affect all residents. The facility census was 54. The facility did not provide a policy on narcotic reconciliation documentation. 1. Review of the 100 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 A.M.-6 P.M. shift on 02/03/25-02/24/25, the staff missed 13 out of 44 opportunities to reconcile the narcotic medications; - For 6 A.M.-6 P.M. shift on 02/25/25-03/07/25, the staff missed 6 out of 21 opportunities to reconcile the narcotic medications. 2. Review of the 200 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 P.M.-6 A.M. shift on 02/10/25-03/07/25, the staff missed 22 out of 47 opportunities to reconcile the narcotics medications. 3. Review of the 300 Hall Medication Cart Narcotic Count Log for Controlled Substances…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (medications that affect a person's mental status) medication for three residents (Residents #1, #15, and #20) out of five sampled residents. The facility census was 54. Review of the facility's policy titled, Antipsychotic (a medication that affects the brain activities associated with mental processes and behavior) Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): 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 before2025-03-07 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 54. Review of the facility's policy titled, Refrigerators and Freezers, dated November 2022, showed: - The facility will ensure safe refrigerator and freezer temperatures, and sanitation, and will observe food expiration guidelines; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures with first opening and at closing in the evening; - Use by dates are completed with expiration dates on all prepared food in refrigerators; - Expiration dated on unopened food and observed and use by dates are indicated once food is opened. Review of the facility's policy titled, Food Preparation and Service, dated November 2022, showed: - Food and nutrition services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-04 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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) out of four sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 57. The administration was notified on 01/26/25 of the Past Non-Compliance which occurred between 01/25/25 through 01/26/25. On 01/26/25, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 01/26/25, as the facility completed disciplinary action for Housekeeper A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. Review of the facility's policy titled, Abuse Prevention Program, revised September 2021, showed: -Misappropriation of resident property defined as deliberate misplacement,…
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 · E2024-12-18 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 12 residents (Resident #9, #17, #18, #26, #27, #28, #29, #30, #31, #32, #33 and #34). The facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for five residents (Resident #1, #2, #3, #6 and #7) out of a sample of seven. Facility staff also failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner, which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for five residents (Resident #2, #3, #4, #6 and #9) out of a sample of five. The facility census was 53. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 12/05/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-18 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 34 residents. The census was 53. 1. Record review of the facility maintained bank statements for the account ending in 2107 for the months 12/2023 through 11/2024 showed no documentation of reconciliations for the following months. Month 12/2023 06/2024 07/2024 09/2024 10/2024 11/2024 Record review of the facility maintained attempted reconciliation forms for account ending in 2107, dated 12/2023 through 09/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of the attempted reconciliation and showed no attempted reconciliation for 10/2024 through 11/2024. During an interview on 12/05/24 at 11:46 A.M., the Regional Accountant and Business Office Manager said 10/2024 and 11/2024 books had not been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one of four sampled discharged residents (Resident #18) and for one of five expired residents (Resident #16). The facility census was 53. 1. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #18 discharged on [DATE]. Record review of the facility maintained Trust Transaction History Report for the period [DATE] through [DATE], showed Resident #18's money was not refunded until [DATE], 70 days after the discharge date . During an interview on [DATE] at 2:44 P.M., the Regional Accountant said the money was not refunded timely due to trying to close out the books. 2. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #16 expired on [DATE]. Record review of the facility maintained Resident Trust Fund Statement for the period [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-27 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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) out of three sampled residents was free of misappropriation of his/her property when Certified Nurse Aide (CNA) A utilized the resident's bank card for his/her own personal use. The facility census was 55. The administration was notified on 08/27/24 of the Past Non-Compliance which occurred between 08/09/24 through 08/14/24. On 08/14/24, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 08/14/24, as the facility completed disciplinary action for CNA A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. Review of the facility's policy titled, Abuse Prevention Program, revised September 2021, showed: -Misappropriation of resident property defined as deliberate misplacement,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-03 · 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 provide resident care for activities of daily living (ADLs) when the residents did not receive a minimum of two showers per week for nine residents (Resident #6 #15, #18, #21, #27, #29, #34, #41 and #44) ) out of 15 sampled residents and two residents (Resident #43 and #46) outside of the sample. The facility's census was 57. Review of the facility policy titled, Supporting Activities of Daily Living (ADLs), revised March 2018, showed: - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Appropriate care and services will be provided for residents who are unable to carry out ADLs in accordance with the plan of care including hygiene (bathing, grooming and oral care). Review of Resident #6's medical record showed: - An admission date of 05/11/22; - Diagnoses of schizophrenia (a long term mental disorder that affects a person's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the resident's dignity was maintained while performing wound care for one resident (Resident #42) out of two sampled residents. The facility census was 57. Review of the facility policy titled, Dignity, revised February 2021, showed staff are to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident #42's quarterly Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility, dated 09/28/23, showed: - Moderately impaired cognitive skills; - Sometimes understands others; - Makes self understood; - Diagnoses of pressure ulcers, (localized damage to the and/or underlying tissue as a result of pressure), schizophrenia (chronic mental disorder), and morbid obesity (excessive body fat that presents a health risk). Observation on 11/02/23 at 3:32 P.M. showed Licensed Practical Nurse (LPN) B and Nursing Assistant (NA) E performed wound care to Resident #42's coccyx, right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) a federally mandated assessment to be filled out by the facility staff, within 14 days of an admission to hospice for for one resident (Resident #37) out of three sampled residents. The facility census was 57. The facility did not provide a policy regarding Significant Change MDS assessments. Review of Resident #37's medical record showed the resident admitted to hospice on 09/15/23. Review of the resident's MDS records showed: - No significant change MDS dated on or after 0915/23; - The facility failed to complete an significant change MDS within 14 days of the resident's admission to hospice. During an interview on 11/02/23 at 2:37 P.M., the MDS Coordinator said that he/she would expect there would be a significant change MDS completed within 14 days of a resident's admission to hospice. During an interview 11/03/23 at 2:34 P.M., the Director of Nursing (DON) said she would expect there would be a significant change MDS completed within 14 days of a resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one resident (Resident #37) of two sampled hospice residents had a complete hospice (palliative care for the terminally ill with a life expectancy of six months or less) coordinated plan of care. The facility census was 57. Record review of the facility's policy titled, Hospice, revised July 2017, showed: - It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative; - Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care, as well as the care and services provided by the facility. Review of Resident #37's medical record showed an admission date of 09/15/23 to hospice. Review of the resident's Hospice Coordinated Task Plan of Care, dated 09/15/23, showed: - admitted to hospice on 09/15/23; - Failed to document the name…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · 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 monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents and failed to update the care plan with new interventions to prevent additional falls for one resident (Resident #34) out of two sampled residents. The facility census was 57. Review of the facility policy titled, Managing Falls and Fall Risks, revised March 2018, showed: - The staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls; - If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant; - The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of and reconciled for one resident (Resident #555) outside of the 15 sampled residents. The facility census was 57. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed: - Controlled substances are counted upon delivery; - If count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance; - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up; - The system of reconciling the receipt, dispensing and disposition of controlled substances includes: Records of personnel access and usage; Medication administration records; Declining inventory records; and Destruction, waste and return to pharmacy records; - Controlled substances remaining in the facility after the order has been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards of practice. This had the potential to affect all residents who resided in the facility. The facility's census was 57. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed: - Controlled substances are separately locked in permanently affixed compartments; - All keys to controlled substance containers are on a single key ring that is different from any other keys. Observation on 11/03/23 at 7:45 A.M., of the main medication room of the unlocked medication refrigerator showed: - One bottle of liquid lorazepam (a controlled medication used to treat anxiety) 2 milligram (mg) per milliliter (ml) for Resident #37; - One bottle of liquid lorazepam 2 mg per ml for Resident #19; - One bottle of liquid lorazepam 2 mg per ml and one bottle of liquid morphine (a controlled medication used to treat pain) 100 mg per 5 ml for Resident #555; - The facility failed to store 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
$14,069 in federal fines across 1 penalty.
- $14,069 — penalty dated 2025-07-31
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 CIRCLE B ENTERPRISES — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.5 | +0.5 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 2.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 1.9 | -0.9 vs chain |
The other 35 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| THE NEW MADRID EXEMPT TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | 100% | since 07/14/2016 |
| BEDELL, DONALD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/14/2016 |
| BEAIRD, TODD | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| AGH1 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/02/2025 |
| SOVEREIGN HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/06/2025 |
| SAHAI, MADHU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/15/2016 |
| WOOTEN, SHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/08/2025 |
| BEDELL, BRYAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/12/2025 |
| DCB REAL ESTATE PARTNERSHIP LP | Organization | ADP OF THE SNF | — | since 08/08/2016 |
| FG LLC | Organization | ADP OF THE SNF | — | since 12/02/2016 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | — | since 08/16/2021 |
| MID STATES INC | Organization | ADP OF THE SNF | — | since 12/15/2016 |
| NEW MADRID RE LLC | Organization | ADP OF THE SNF | — | since 08/08/2016 |
| VAN DE VEN LLC | Organization | ADP OF THE SNF | — | since 01/01/2000 |
CMS files one row per role, so the 22 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 32% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 265859. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.