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Valley View Health & Rehabilitation

1600 East Rollins St, Moberly, MO 65270 · For profit - Individual · 96 certified beds · (660) 263-6887 Medicare & Medicaid certified

Call the home — (660) 263-6887 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Mar 2024Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations$62,733 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2024
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $62,733 in federal fines (most recent 2025-02-25)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1529 Union Ave · (660) 269-8550 · Call to confirm hours
Pharmacy
300 N Morley St · (660) 263-0909 · Call to confirm hours
Grocery
301 S Morley St · (660) 263-7790 · Call to confirm hours
Park
Fox Park1.0 mi
1160 Russhaven Dr · (660) 269-8705 · Typically dawn to dusk
Place of worship
120 W Outer Rd · (660) 263-4361

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.3%18.1%15.4%better
Long-stay residents who lose too much weight0.4%5.3%5.4%better
Long-stay residents with a catheter left in their bladder3.5%1.1%0.9%worse
Long-stay residents with a urinary tract infection2.0%2.3%2.0%typical
Long-stay residents with depressive symptoms35.3%18.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.4%4.1%3.3%better
Long-stay residents whose ability to walk worsened12.4%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.1%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.8%90.9%95.3%typical
Long-stay residents with pressure ulcers5.3%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control11.1%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table24.3%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.1%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine66.7%63.5%79.4%worse
Short-stay residents rehospitalized after admission19.0%26.0%22.6%better
Short-stay residents with an outpatient ER visit24.0%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.172.111.67worse
Long-stay outpatient ER visits per 1,000 resident days2.572.331.80worse

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

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

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

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

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

46.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.5%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
60.0%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 60.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.5%CMS range 32.1–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.8–17.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.5–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.62
RN hours/ resident / day
0.35
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.48
RN hoursweekends
62.5%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 72.5 residents a day — about 76% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 2.59 hrs/resident/day on weekends vs 3.34 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

6
deficiencies at the latest standard inspection (2024-10-08)
5
at the previous standard inspection (2022-11-10)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2025-02-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three residents (Resident #10, #9, and #13), in a review of 13 sampled residents, were treated with dignity and respect. Certified Medication Technician (CMT) F was rude and rough during care for one resident, (Resident #10) and the resident said it hurt his/her feelings and made him/her feel angry. CMT F was rough and forceful with Resident #9's care and the resident said it made him/her feel like he/she wasn't worth anything. Resident #13 reported CMT F was condescending and liked to show his/her authority; the resident said it made him/her so angry he/she wanted to punch CMT F in the face. The facility census was 76. Review of the facility's policy Resident Rights, revised December 2016, showed all employees should treat all residents with kindness, respect, and dignity. Review of the facility's policy Conduct and Behavior, revised May 2019, showed examples of conduct and behavior that were considered inappropriate and therefore prohibited…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-10-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff adequately documented assessments and monitoring of pressure ulcers (any lesion caused by unrelieved pressure, resulting in damage to underlying tissue that usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed) for one resident (Resident #333), in a review of 22 sampled residents; failed to maintain documentation of communication with the resident's physician on the changes to the resident's pressure ulcers to ensure appropriate treatment and care of the pressure ulcers; failed to ensure the resident's physician or designee followed facility policy to examine the resident's pressure ulcers upon readmission to the facility and to evaluate and document the progress of the pressure ulcers during resident visits; and failed to re-evaluate the need for ordered interventions, including a low air loss mattress, when the condition of the resident's pressure ulcers worsened. The pressure…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-10-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff safely transferred two residents (Residents #133 and #21), in a review of 22 sampled residents and one additional resident (Resident #30), who required assistance with transfers. Staff failed to utilize proper transfer technique when transferring Resident #133, when staff did not use a gait belt and did not ensure the resident wore proper foot wear during a transfer which resulted in a fall with injury. The resident sustained a displaced fracture of the tibia/fibula (ankle) as a result of the fall. The facility census was 84. Review of the facility policy, Managing Falls and Fall Risk, revised [DATE], showed the following: -Based on previous evaluations and current data, 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; -According to the Minimum Data Set (MDS), a fall is defined as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided assistance with Activities of Daily Living (ADLs) for two residents (Resident #1 and #7) in a review of 13 sampled residents, to maintain proper grooming to include nail care and personal hygiene. The facility census was 76. Review of the facility's policy Activities of Daily Living (ADL), Supporting, revised March 2018, showed the following: -Resident's will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene; -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, grooming 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide protective oversight to ensure one resident (Resident #1), did not obtain a lighter and cigarettes within the facility on multiple occasions. The resident was also observed smoking in his/her room wearing oxygen and admitted to staff he/she was smoking in the facility. Staff educated the resident not to smoke in the building and on the smoking policy. There was no documentation any other interventions were put in place or the resident's smoking assessment was updated until 2/19/25. On 2/20/25 during the night, the resident was observed smoking and admitted to smoking in the facility on more than one occasion and was found with two lighters and a half pack of cigarettes. The facility census was 76. Review of the facility's policy titled, Smoking Policy, dated 10/2/24, showed the following: -When the resident requested to smoke, the interdisciplinary team (IDT) will assess the resident's capabilities and deficits to determine appropriate…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served to residents in a safe and sanitary manner when staff failed to utilize proper hand hygiene and gloving techniques, hair restraint usage, surface sanitation, food storage, and dish handling and storage. The facility census was 84. 1. Review of the facility policy, Food Preparation and Service, revised 4/2019, showed the following: -Food and nutrition services employees will prepare and serve food in a manner that complies with safe food handling practices; -Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays; -Gloves are worn when handling food directly and changed between tasks. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised 10/2017, showed the following: -Food and nutrition services employees will follow appropriate hygiene…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care to prevent the development and transmission of diseases and infections for four residents (Residents #21, #40, #283, and #31), in a review of 22 sampled residents, and four additional residents (Resident #71, #38. #79 and #50). Staff failed to perform appropriate hand hygiene during personal care for Residents #21 and #71; failed to utilize Enhanced Barrier Precautions (EBP) during personal care for Resident #71 who had a gastrostomy tube (a flexible tube that is surgically inserted through the abdominal wall and into the stomach that allows for the delivery of nutrition and medication directly into the stomach); failed to ensure Resident #40's urinary catheter (tube inserted into the bladder to excrete urine from the body) drainage bag was stored off the floor; failed to ensure Resident #283's wound vac (a treatment device that uses pressure to help close wounds and increase healing) was kept up off the floor while in use;…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oral hygiene for two residents (Residents #41 and #48), who required assistance with oral care, in a review of 22 sampled residents. The facility census was 84. Review of the facility's policy, Mouth Care, revised February 2018, showed the following: -Purpose of the procedure was to keep the resident's lips and oral tissues moist, to cleanses and freshen the mouth, and to prevent oral infection; -The following should be documented in the resident's medical record; -1. The date and time the mouth care was provided along with the name and title of the individual who provided the mouth care; -2. Complaints of pain or discomfort of the mouth; -3. If the resident refused the treatment, the reason why, and the intervention taken; -4. The signature and title of the person recording the data. (The facility policy did not direct staff on how often they should provide oral care.) 1. Review of Resident #41's undated medical diagnosis 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-08 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    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 the Medical Director or his/her designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. The facility census was 84. Review of the facility's QAPI Plan, dated March 2020, showed the following: -The Quality Assessment and Assurance (QAA) committee was designed to address quality deficiencies through analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level; -QAA committee was responsible for analyzing identified problems, establishing, corrective actions, measuring progress against the established goals and benchmarks, and communicating information to staff and residents and reporting findings to the administrator and governing board; -The QAA committee consisted of the Administrator, all department heads, Medical Director, and Pharmacist. 1. Review of the QAA meeting attendance log, dated 07/30/24, showed no documentation the facility's Medical Director and/or designee attended the meeting. Review of the QAA meeting…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #2 and #7) in a review of seven sampled residents, who the facility identified as dependent on staff for Activities of Daily Living (ADLs), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to ensure Resident #2 was kept clean and dry, repositioned in bed, provided access to a call light, and had access to water and fluids. Staff also failed to provide incontinence care to Resident #7 for over seven hours when the resident had informed staff. Instead of providing care, staff covered the resident's soiled bed linens with a towel. The facility census was 84. Review of the facility policy, Activities of Daily Living (ADL), Supporting, dated March 2018, showed the following: -Residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Residents who were unable to carry out…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident, in a review of seven sampled residents (Resident #2), who had an indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder), and who had a history of urinary tract infections (UTI), was provided with urinary incontinence care and indwelling catheter care in a manner to prevent the spread of bacteria that cause infections. The facility had 12 residents with indwelling urinary catheters. The facility census was 84. Review of the facility policy Urinary Catheter Care dated September 2014, showed the following: -The purpose was to prevent catheter-associated urinary tract infections; -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag; -Do not clean the periurethral area with antiseptics to prevent catheter-associated urinary tract infections while the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for one resident (Residents #2), in a review of seven sampled residents. The facility census was 84. Review of the facility policy Handwashing/Hand Hygiene, dated August 2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap and water when the hands were visibly soiled and after contact with a resident with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-06 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prevent misappropriation of three residents' (Resident #1, #2 and #3) narcotic pain medication when certified medication technician (CMT) A removed one hydrocodone-acetaminophen (a combination medication used to relieve pain containing an opioid pain reliever and a non-opioid pain reliever) 5 milligrams (mg)/325 mg pill from Resident #1's and #3's narcotic medication card and removed two hydrocodone 10 mg/325 mg pills from Resident #2's narcotic medication card and admitted to ingesting them while on duty. The facility census was 81. The administrator was notified on 3/6/24 of the past non-compliance which occurred on 2/27/24. On 2/27/24 the consulting pharmacist was at the facility conducting a random spot check of medications. The pharmacist counted narcotics with CMT A and found medications that were missing from three residents' narcotic cards. The pharmacist asked what happened to them and CMT A admitted to ingesting the medications. Upon discovery, the administrator suspended CMT A, assessed all…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
Show the remaining 12 citations
  • Potential for harm · D2024-01-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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

    Based on interview and record review, the facility failed to protect one resident (Resident #3), in a review of five residents, from physical abuse when Licensed Practical Nurse (LPN) B witnessed Certified Nurse Assistant (CNA) A pushing down and holding Resident #3's arms that were crisscrossed on the resident's chest while the resident hollered out with a red face. LPN B noted red marks on the resident's wrist and forearm following the incident. The facility census was 85. On 1/11/24 at 2:00 P.M., the administrator was notified of the past noncompliance which occurred on 12/31/23. On 12/31/23, the administrator identified CNA A physically abused Resident #3. Upon discovery, staff suspended CNA A, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff members were educated on the facility abuse and neglect policies. CNA A was terminated from employment. The deficiency was corrected on 1/2/24. Review of the facility policy, Abuse Prevention Program, dated December 2016, showed the following: -The residents…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2022-11-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment by failing to ensure residents' rooms and living spaces were clean and in good repair. The facility census was 67. 1. Observations on 11/07/22 at 10:55 A.M. and on 11/8/22 at 7:04 A.M. in occupied resident room [ROOM NUMBER] showed a strong urine odor. Observations on 11/8/22 at 10:31 A.M. and on 11/9/22 at 10:31 A.M. in the bathroom in occupied resident room [ROOM NUMBER] showed a strong urine odor. A soiled uncovered urinal, graduate, and bed pan were stored on the shelf above the toilet. 2. Observation on 11/08/22 between 8:00 A.M. and 2:50 P.M., during the life safety code tour of the facility, showed the following: -In the main dining room, eleven, 4-inch by 4-inch ceiling vents were covered in a thick layer of dust; -In the human resources office, a five inch round ceiling vent was covered in a thick layer of dust; -In the copy room, a four foot light did not have a cover; -In the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for three residents (Residents #17, #51, and #52), in a review of 22 sampled residents, and failed to practice clean technique during medication administration for one additional resident (Resident #31). The facility census was 66. Review of facility policy Handwashing/Hand Hygiene, last revised August 2015, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infection; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap (antimicrobial 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and observation, the facility failed to provide proper care to a urinary catheter (a tube inserted in to the bladder to excrete urine out of the body), for one resident (Resident #17), in a review of 22 sampled residents, Nine residents had a urinary catheter. The facility census was 66. Review of the facility policy, Urinary Catheter Care, last revised September 2014, showed the following: -The purpose of the procedure was to prevent catheter-associated urinary tract infections; -Use a washcloth with warm water and soap to cleanse around the meatus (a part of the genitalia). Cleanse the glans (a part of the genitalia) using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 1. Review of Resident #17's care plan, dated 4/19/22, showed the following: -He/She had a urinary catheter due to a neurogenic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-03 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    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 complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) a federally mandated assessment instrument required to be completed by facility staff) for four residents (Residents #18, #5, #6, and #28) in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 64. 1. During interview on 5/3/19 at 3:55 P.M. the MDS Coordinator said he/she followed the Resident Assessment Instrument (RAI) 3.0 manual while completing residents' MDS. 2. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-03 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided three of 17 sampled residents (Resident # 52, #30 and #46) who were unable to complete their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 64. 1. Review of the facility policy Mouth Care dated 2/18 showed the purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and and to prevent oral infection. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Equipment and supplies: toothbrush, toothpaste, emesis basin, towel, fresh water, mouthwash, disposable cup, straw, applicators or gauze sponges, lubricants and personal protective equipment. Steps in the procedure: place the equipment on the bedside stand or over bed table. Arrange the supplies so they can be easily reached. Wash…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-03 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon interview and record review, the facility failed to offer bedtime snacks to residents. During the group interview all residents present (Residents #44, #24, #55, #49, #36, #47, #12, #7, #16 and #2) said staff did not deliver or offer snacks in the evening. The facility census was 64. 1. Review of the facility policy, Snacks (Between Meal and Bedtime), Serving, dated 2001 and last revised 9/14 showed the following: The purpose of this procedure is to provide the resident with adequate nutrition; Preparation: 1. Review the resident's care plan and provide for any special needs of the resident; 2. Assemble equipment and supplies needed. 3. Check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; 4. Ensure that the necessary non-food items (i.e., flexible straw, special devices, etc.) are on the tray. Report or replace missing items; Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: snack tray,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for five residents (Resident #6, #38, #39, #46 and #30) in a review of 17 sampled residents. The facility also failed to ensure staff appropriately disinfected a urine soiled mattress for one resident (Resident #46). The facility census was 64. 1. Review of facility policy Handwashing/Hand Hygiene last revised 8/15 showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infection; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap (antimicrobial 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that two residents (Resident #38 and #39) urinary catheter (tube inserted into the bladder to drain urine) drainage bags and/or tubing were kept off the floor in a review of 17 sampled residents. Resident #38 had a significant history of urinary tract infections (UTIs) and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to malfunctioning of various organs, shock, and death). The facility census was 64 . 1. Review of the facility policy, Catheter Care, Urinary dated 2001 and last revised 9/14 showed: Infection Control 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one resident's (Resident #18) orders for as needed (PRN) psychotropic drugs were limited to 14 days as required except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration of the PRN order and failed to ensure one resident (Resident #30) who received multiple psychotropic medications (including three sedative type medications at bedtime), had any documented, attempted Gradual Dose Reductions to include the request, decision from physician and/or the rationale for the refusal. The facility census was 64. 1. During interview on 5/3/19 at 4:30 P.M. the Director of Nursing said the facility did not have a policy for PRN use of psychotropic medications. 2. Review of the facility policy Tapering Medications and Gradual Drug Dose Reduction (GDR), dated 2001 and last revised…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-11-10 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify two residents (Residents #20, and #21), in a review of 22 sampled residents, one closed record (Resident #67), and one additional resident (Resident #11) and/or their representatives in writing of transfer to the hospital, including the reasons for the transfer. The facility census was 66. Review of the facility's Transfer or Discharge Documentation, revised December 2016, showed the following: -When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -That an appropriate notice was provided to the resident and/or legal representative; -The date and time of the transfer or discharge; -The new location of the resident; -The mode of transportation; -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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-11-10 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 66. Review of the facility policy, Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the following: -Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. -Within two hours of the beginning of each shift, the number of licensed nurses (registered nurses, licensed practical nurses, and licensed vocational nurses) and the number of unlicensed nursing personnel (certified nurse assistants) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format; -Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$62,733 in federal fines across 2 penalties.

  • $24,786 — penalty dated 2025-02-25
  • $37,947 — penalty dated 2024-10-08

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 MO OP HOLDCO, LLC — 9 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 →

RatingThis homeChain avg
Overall 3 of 52.6+0.4 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 3 of 53.3-0.3 vs chain
The other 8 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleShareSince
FRIEDMAN, ZELIGIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF6%since 08/13/2021
LICHTENSTEIN, ELIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF39%since 08/13/2021
LICHTENSTEIN, ISAACIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF11%since 08/13/2021
MANDELBAUM, CHAIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF43%since 03/11/2024
NEWPOINT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 08/13/2021
BARNES, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/13/2021
KRAMER, SHMUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/13/2021
PERKINS, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/13/2021

CMS files one row per role, so the 20 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$6.8M
Net patient revenuemost recent cost report
+7.1%
Operating marginrevenue minus expenses
$593K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 7%Other / private 22%

About 72% 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 $593K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$220per resident / day
operating cost
$6,679per month
≈ monthly operating cost
$237per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265536. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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