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Lawrence County Manor

915 Carl Allen Street, Mount Vernon, MO 65712 · Government - County · 90 certified beds · (417) 466-2183 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0602) — cited Dec 2025Resident-funds citation (F0565)1 immediate-jeopardy citation$13,762 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,762 in federal fines (most recent 2023-09-11)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (93%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
624 E Mount Vernon Blvd · (417) 466-2875 · Call to confirm hours
Pharmacy
1319 S Landrum St · (417) 461-1100 · Call to confirm hours
Grocery
480 E Daniel Dr · (417) 466-4646 · Call to confirm hours
Park
425 E Mt Vernon Blvd · Typically dawn to dusk
Place of worship

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 2 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 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.

Overall rating1★
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 increased21.7%18.1%15.4%worse
Long-stay residents who lose too much weight7.4%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%1.1%0.9%better
Long-stay residents with a urinary tract infection10.4%2.3%2.0%worse
Long-stay residents with depressive symptoms1.8%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.2%4.1%3.3%worse
Long-stay residents whose ability to walk worsened21.1%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication42.4%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine95.8%90.9%95.3%typical
Long-stay residents with pressure ulcers4.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control17.2%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.6%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine50.0%63.5%79.4%worse
Short-stay residents rehospitalized after admission15.4%26.0%22.6%better
Short-stay residents with an outpatient ER visit4.7%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.232.111.67better
Long-stay outpatient ER visits per 1,000 resident days2.542.331.80worse

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.

39.6% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.6%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
46.1%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 46.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.6%CMS range 26.3–52.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.8–14.310.7%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 discharge46.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.1%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 identified84.8%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 worsened2.2%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.07
RN hours/ resident / day
0.14
LPN hours/ resident / day
0.19
Aide hours/ resident / day
0.39
Total nurse hours/ resident / day
0.01
RN hoursweekends
93.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 90 beds and averages 67.4 residents a day — about 75% occupied, or roughly 23 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 0.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.07 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.19 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 0.26 hrs/resident/day on weekends vs 0.45 on weekdays — 42% thinner on weekends — a notable drop. RN hours go from 0.09 to 0.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 93% 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

8
deficiencies at the latest standard inspection (2025-08-13)
8
at the previous standard inspection (2023-09-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-08-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents' environments were free of accident hazards when the facility failed to implement a process to ensure resident accessible hot water temperatures in all resident access areas were maintained at a safe temperature resulting in the hot water in 12 residents rooms (Resident #2, #12, #24, #25, #6, #68, #36, #34, #15, #44, #55, and #38) and a common bath/shower room to measure between 125.6 to 138 degrees Fahrenheit (F). The facility census was 70.The Administrator was notified on 08/08/25, at 1:55 P.M., of an Immediate Jeopardy (IJ) which began on 08/05/25. The IJ was removed on 08/09/25 as confirmed by surveyor on-site verification. Review of the American Burn Association website, updated 2002, showed the following:-Hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white of blackened, charred skin) at the following temperatures and time parameters:-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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-02 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible physical abuse by staff involving one resident (Resident #1). Management and DHSS were not made aware of the allegation until the following day. The facility census was 66. Review of the facility policy titled Abuse, undated, showed the following:-The facility will ensure each resident is free from abuse, neglect, misappropriation of resident property, and exploitation;-Every staff member must immediately report any observed or suspected abuse of a resident by another staff member, resident, family member, or visitor;-The Director of Nursing (DON) will ensure all alleged violations are reported immediately, but not later than 2 hours after the allegation is made if the allegations involve abuse or result in serious bodily injury;-The DON will report to the Administrator of the facility and to other…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely investigate an allegation of abuse and ensure protection of all residents during the investigation when after receiving an allegation of possible staff physical abuse involving one resident (Resident #1) the staff did not begin an investigation until the next day and allowed the staff member to continue to work with residents independently. The facility had a census of 66. Review of the facility policy titled Abuse, undated, showed the following:-The facility will ensure each resident is free from abuse, neglect, misappropriation of resident property, and exploitation;-The facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;-The facility will ensure that all alleged violations are thoroughly investigated; -The Director of Nursing (DON) will immediately initiate an abuse incident report and begin investigation of alleged abuse;-The DON will prevent further potential abuse while the investigation is in progress;-Report the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-12 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and accounting of all drugs when eight cards of narcotics for eight residents (Resident #3, #4, #5, #6, #7, #8, #9 and #10) were found in the former Director of Nursing's (DON's) office desk. The facility census was 64.Review of a facility policy entitled Medications, Narcotics, undated, showed the following:-Narcotics will always be stored under a double lock system;-Each narcotic that the pharmacy dispenses to the facility is accompanied by a narcotic record;-Narcotics will be counted at the beginning and end of each shift by the nurse or CMT ending their shift and the nurse or CMT beginning the shift;-Discontinued narcotics must be pulled from the medication cart and placed in a locked box in the medication room with their narcotic sheets attachedReview of a facility policy entitled Medication Storage and Handling, undated, showed the following:-Medications will only be…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-12 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure all residents were free from misappropriation of property when staff used one resident's (Resident #1) credit card without resident permission and when staff took money from one resident (Resident #2). The facility census was 64.Record review of the facility's policy titled Abuse, undated, defined exploitation as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. The same facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), completed 08/18/25, showed diagnoses included non-Alzheimer's dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a serious mental health condition that affects…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, and failed to ensure the dishwasher washed and rinsed the dishes at the recommended temperatures. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 70 residents.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Date Marking and Food Storage Policy and Procedure. revised 09/19/24, showed the following: -All food stored for more than 24 hours will be properly identified and marked according to the following guidelines;-Unopened cases of dry food items will be dated with the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-13 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop 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 implement their abuse and neglect prevention policies, when they failed to complete an employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) check and a check of the Nurse Aide (NA) Registry (a list checking for a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) for four staff members (Housekeeper (HK) S, Certified Nurse Aide (CNA) T, Dietary Aide (DA) U, and Dietary [NAME] (DC) N) of ten sampled records. The facility census was 70.Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, showed the facility will conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-13 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 all residents were appropriately screened prior to placement in a nursing home when the facility failed to obtain documentation of Preadmission Screenings and Resident Reviews (PASARR) for two residents (Resident #2 and #69). The facility census was 70.Review of the document the facility provided as their policy titled Missouri Department of Health & Senior Services Level One Form Training, dated 02/08/24, showed the following:-The PASARR process requires that all applicants to Medicaid-certified nursing facilities (regardless of whether their stay will be covered by private funds, Medicare, or Medicaid) be given a preliminary assessment to determine whether they might have a serious mental illness (SMI) or an intellectual disability (ID);-PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care;-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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-13 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to prepare pureed diets per approved recipes and failed to provide the approved serving size for pureed meals. The facility census was 70.Review of the facility policy titled, Puree Step by Step Guide, undated, showed the following:-Count items needed for puree as you are placing it into the food processor, and make two additional portions above your number of puree diets;-Gradually add hot liquid of choice with food to puree to a pudding like consistency (gravy/broth/hot milk-never use water);-Scrape sides of food processor and continue blending until there are no lumps/bumps in puree;-Use tongs to take blade out of food processor and use spatula to scrape product into serving pan;-Re-heat puree product in steam water bath on stove to 165 degrees Fahrenheit (F) or greater. 1. Review of the facility's recipe for pureed jambalaya showed the following:-Prepare according to the regular jambalaya recipe;-Blend until smooth and serve one cup…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standard and the resident's choices when the facility failed to follow-up regarding a cardiology referral for one resident (Resident #40), who had a pacemaker, in a timely manner. This would place the resident at an increased risk for a cardiac incident due to lack of oversite on his/her pacemaker. The facility census was 70.Review of the facility provided policy titled, Verbal Orders, revised February 2014, showed the following:-Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order;-Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols;-Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record;-Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe…

    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 · D2025-08-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on interview and record review, the facility failed to ensure each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence possible when staff failed to provide restorative nursing services three times weekly per the restorative therapy program for one resident (Resident #52). The facility census was 70.Review of the facility policy titled, Restorative Nursing Services, revised July 2017, showed the following:-Residents will receive restorative nursing care as needed to help promote optimal safety and independence;-Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational, or speech therapies);-Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care;-Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care;-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
Show the remaining 21 citations
  • Potential for harm · Dcited before2025-08-13 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure correct installation and maintenance of bed rails when the bed rail of one resident (Resident #11) was loose and improperly secured. The facility census was 70.Review of the facility policy titled, Bed Rail Policy, dated 2017, showed the following:-It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use;-A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenance and individual bed rail evaluations;-In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g. rails, frames, and mattresses, and operational components) to ensure they are clean, comfortable, and safe;-The facility will also ensure individual resident bed rail evaluations are performed on a regular basis;-Individual bed rail evaluations will include data collection analysis 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 · D2025-05-02 · 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

    Based on interview and record review, the facility failed to ensure each resident was treated with respect and dignity at all times when the facility staff made harsh and upsetting comments to one resident (Resident #1) in front of other residents; when staff threatened two resident's (Resident #1 and #3) smoking rights if they shared cigarettes with one resident (Resident #1); and when staff talked with one resident (Resident #4) regarding being friends with one resident (Resident #1). A sample of six residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Dignity, revised February 2021, showed the following information: -Residents are treated with dignity and respect at all times; -Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person, or entity associated with the facility; -Staff are to speak respectfully to residents at all times; -Staff are to protect confidential clinical information. Verbal staff to staff communication should be conducted outside the hearing range of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement and maintain an effective pain management for all residents when staff failed to accurately and consistently document pain levels and steps taken to address pain, failed to document timely physician notification of pain, and restricted a resident's access to certain medications without a physician order for one resident (Resident #1) out of six sampled residents. The facility census was 65. Review of the facility's policy titled Pain Care, undated, showed the following information: -The effectiveness of the facility's pain care program will be examined monthly; -Pain assessments should include the location, description, frequency, level, what alleviates or exacerbates the pain, history and effectiveness of pain medications, and the residents desires about future pain care; -For residents with daily or chronic pain, maximum relief is achieved with around the clock medications and as needed (PRN) medications for breakthrough pain; -New interventions must be implemented when old interventions are…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to follow proper technique during a mechanical lift transfer of one resident (Resident #1). The facility census was 68. The Director of Nursing (DON) was notified by facility staff on 04/24/24 of the noncompliance that occurred on 04/24/24. The DON and Administrator made an online self-report to the Department of Health and Senior Services, began an investigation, and began in-servicing with all nursing staff regarding transfers on 04/24/24. The facility implemented monitoring of the resident involved and all residents who required a two person assistance transfer assistance with a Hoyer lift (mechanical lift normally used to transfer non-weight bearing residents) to ensure transfers were completed safely and as required with two staff. The noncompliance was corrected on 04/25/24. Review of the facility policy titled, Safe Lifting and Movement of Residents, with 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-10-10 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all allegations of abuse were immediately reported to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed one resident (Resident #1) touch another resident (Resident #2) in a sexual manner and the nurse failed to report the allegation to management or the SSA. The facility census was 62. Review of the facility's policy titled Abuse Reporting, revised 03/15/18, showed the following: -It is the policy of the facility that all personnel promptly report any incident or suspected incident of resident abuse; -The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends or other individuals; -Any alleged violations involving mistreatment, neglect, or abuse must be reported to the Administrator and/or Director 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents when Certified Nurse Aide (CNA) B alleged one resident (Resident #1) was observed to touch another resident (Resident #2) in a sexual manner. The facility census was 62. Review of the facility policy titled Abuse Investigating, revised 03/15/18, showed the following: -It is the policy of the facility that reports of abuse will be promptly and thoroughly investigated; -The administrator will provide to the person in charge of the investigation a copy of the Resident Abuse Report Form and any supporting documents relative to the investigation: -The representative's investigation shall consist of a review of the completed Resident Abuse Report Form and an interview with the person(s) reporting the incident. Review of the facility's Abuse Policy included a copy of a form, including the steps taken to protect residents, which showed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to clean the hand washing sink, sink in the food preparation area, floor under the three vat sink, the area between the wall and the stove, fryer, and warming cart, the vent above the ice machine, and failed to repair the walls behind the dishwasher and in the beverage room and tiles and wall under the three vat sink to ensure they were washable surfaces; staff failed wear hair nets appropriately to prevent contamination of food; staff failed to regularly test and have knowledge of the correct temperatures of the dishwashing machines; and the drain from the ice machine had no air gap between it and the drain. The facility census was 60. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-22 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for four residents (Resident #16, #25, #29, and #31). The facility census was 60. Review of the facility's policy titled, Advance Directives, revised [DATE], showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Review of Resident #'16's face sheet (admission data) showed the following: -admission date of [DATE]; -Code status of Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR-an emergency…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 document a full discharge summary with information regarding discharge for one resident (Resident #59). The facility census was 60. Review of the facility's policy titled, Discharge Procedure, revised 04/26/00, showed the following: -To assist family and resident to continue care if returning home; -To advise other departments promptly of dismissal; -To facilitate proper closing of records and collection of personal belongings; -Upon notification of dismissal, the records will be completed as quickly as possible assuring an organized dismissal. 1. Review of Resident #59's face sheet (admission data) showed the following information: -re-admission date of 04/14/18; -Diagnoses included unspecified dementia, obesity, and anxiety disorder. Review of the resident's progress note dated 06/28/23, at 2:14 P.M., showed the Social Service Director (SSD) documented the resident to discharge on [DATE]. The resident will stay with his/her family member. Nursing…

    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 · Dcited before2023-09-22 · 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

    Based on observation, interview, and record review, the facility failed to provide timely and routine assessments, failed to consistently provide physician ordered treatment and antibiotic, and failed to develop a baseline and comprehensive care plan for one resident (Resident #61) with a right heel pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three sample of three closed record (discharged ) residents. The facility census was 60. Review of the facility policy, Decub (pressure ulcer) Care Protocol, dated 02/01/07, showed staff to assess the resident at least weekly and document the assessment in the skin book and nurses notes. Review of the facility policy, Pressure Ulcers/Injuries Overview, revised July 2017, showed the following: -The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors; -Pressure ulcer/injury (PU/PI) refers to localized damage to the skin and/or underlying…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain physician orders for the care and treatment of one resident's (Resident #3's) colostomy (a surgical opening on the outside of the body called a stoma. The opening creates a passage from the large intestine to the outside of the body for passage of feces.) out of two sampled residents with stomas. The facility census was 60. Review of the facility policy titled, Colostomy/Ileostomy Care/Irrigation, undated, showed the following: -Goal to promote positive self-image and comfort by maintaining clean, odor-free environment without peristomal (around the stoma) skin excoriation. Prevent constipation or bowel obstruction and establish bowel regularity by cleansing intestinal tract of fecal material; -Physician's order regarding type of irrigation, amount, frequency, type and location of ostomy stoma, time and frequency of irrigation usually performed, ability and willingness of resident to participate in self-care, peristomal skin condition, stoma discharge for color, amount, odor, and consistency of fecal material;…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 ensure all residents received assistance to maintain proper nutrition and hydration unless unavoidable when staff failed to ensure one resident (Resident #6) received his/her ordered house shakes two times daily and failed to ensure a physician order was appropriately received when a staff member placed a nothing by mouth (NPO) sign on the outside of one resident's door (Resident #41). A sample of two residents were reviewed in a facility with a census of 60. Review of the facility's policy titled Weight Assessment and Intervention, revised 03/22, showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Interventions for undesirable weight loss are based on careful consideration of the following: resident choice and preferences; nutrition and hydration needs of the resident; functional factors that may inhibit independent eating; environmental factors that may inhibit appetite or desire to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    3. Review of the facility's policy titled Administering Medications, dated 04/2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing Services (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose; -New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to prevent possible cross contamination of the residents' food during preparation and service when staff did not properly store and label food to prevent contamination or spoilage; did not perform proper food handling techniques; did not properly store clean dishware; and did not provide a require air gap for the drainage of the ice machine. The facility had a census of 49. 1. Record review of facility's policy on food storage, dated 10/26/12, showed the following: -Facility staff to label all food items held for more than 24 hours; -The label must include the name of the food and the date it should be consumed or discarded; -Facility staff to wrap food properly and never leave any food item uncovered or unlabeled. Observations starting on 1/13/20, at 9:40 A.M., in the dry storage area of the kitchen showed the following: -A large 25 pound bag of sugar cookie mix open and rolled shut (not sealed or covered). The sugar cookie mix did not have an open or use by date; -One 16 ounce bag of Cream Soup base open and sealed in Ziplock…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-21 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to respond, address and provide feedback regarding concerns expressed by multiple residents attending the resident council meetings. The facility census was 49. 1. During the Resident Council interview on 1/14/20 at 1:00 P.M., 8 residents attended the meeting and shared the following concerns: -During resident council meetings, the activity director (AD) took notes of the residents' concerns and gave the notes to the department heads; -At each meeting, the AD did not review the concerns from the previous month; -Staff did not resolve issues brought up in resident council, and staff gave no real rationale for not responding to requests. Sometimes the staff gave them was they would go over it or they were working on it. -Concerns included: Staff served meals late, food was cold; and the residents did not always get the food they ordered, or the staff mixed up their orders; -Other concerns included call lights, staffing, and laundry; -Without staff responses nothing gets changed making resident council was a waste of time. 2.…

    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 · E2020-01-21 · tag F0575 — pattern
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to post the required abuse/neglect hotline information in a prominent location for residents, visitors, and staff to review. The facility census was 49. 1. Observation on 1/21/20 at 1:05 P.M., showed the facility posted the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information on the top left corner of a bulletin board located behind a water fountain in the main lobby. The posting measured approximately 8 inches x 10 inches, and was written in fine print which may not be visible to all residents and visitors. The facility did not have the DHSS Abuse and Neglect Hotline information posted in any other area of the facility. During the Resident Council interview on 1/14/20 at 1:00 P.M., eight council members said they did not know where or if there was information related to the DHSS Abuse and Neglect Hotline posted in the facility. During an interview on 1/21/20 2:35 P.M., the Administrator said the State agency information should be posted where all residents, family and visitors could easily see…

    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 · E2020-01-21 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 an ongoing program of meaningful activities based on their interests and abilities for four residents (Resident #8, #20, #28 and #43) residing in the Special Care Unit (SCU) out of a selected sample of 14 residents. The facility's census was 49. Record review of the facility's policy titled, Resident Activities showed the following: -A staff member is hired or designated as the Activity Director (AD) by the administrator; -This facility will provide an on-going program of meaningful activities appropriate to the needs and interests of the residents and designated to promote opportunities for engaging in normal pursuits of daily living including religious activities of their choice, if any; -Activities will be planned on a monthly basis and posted in an area easily accessible to all residents; -Individual activities as well as group activities will be provided; -The opportunity to participate in religious activities will be provided…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-01-21 · tag F0923 — pattern
    Have enough outside ventilation via a window or mechanical ventilation, or both.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when 13 residents' bathrooms did not have functioning exhaust vents. The facility had census was 49. 1. Observation on 1/13/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident rooms did not have functioning exhaust ventilation system when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. During an interview on 1/13/2020, at approximately 1:00 P.M., the Maintenance Supervisor (MS) said he did not know the residents' bathroom exhaust systems did not work The exhaust systems worked off of fans located on the roof.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-21 · 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 observation, interviews, and record review, the facility failed to utilize acceptable infection control practices while performing pressure ulcer care, failed to obtain treatment orders timely for new wounds, failed to care plan and implement pressure ulcer precautions, and failed to complete accurate and complete tracking of wounds for two residents (Resident #18 and #199). The facility census was 49. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following: -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and epithelialization (healing outer layer of a body's surface over a denuded (loss of surface layer of skin) surface; -To monitor progress or deterioration, the examiner must accurately…

    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 before2020-01-21 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to compete a side rail assessment, to include a risk/benefit review ad alternatives attempted prior to use, and failed to obtain informed consent for side rails for two residents (Residents #13 and #199). The facility census was 49. Record review of the facility's policy titled Side Rail Policy, dated 3/2015, showed the following: -Use of side rails can create accidents/falls with greater impact than if side rails were not used; -The facility will assess resident to eliminate unnecessary use of side rails; -Risks to side rails will be identified; -Alternatives to side rails will be considered; -The resident has the right to make choices regarding side rails; -An assessment will be completed at least quarterly to as assess the need for use of side rails. 1. Record review of Resident #199's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 1/4/20; -Diagnoses included…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-09-22 · 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 the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 60. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. 1. Observation on 09/20/23, at 9:15 A.M., showed the nurse staffing information posted on the wall behind the nurses' station above the printer. This was not in a prominent location for residents and visitors to readily view. The posting was dated 02/23/23. During an interview on 09/20/23, at 2:51 P.M., Licensed Practical Nurse (LPN) F said the night shift nurse completes the staffing information. During an interview on 09/22/23, at 11:41 A.M., LPN G said the following: -He/she worked as an agency nurse on the night shift about four times at the facility; -He/she did not know to…

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

    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

$13,762 in federal fines across 1 penalty.

  • $13,762 — penalty dated 2023-09-11

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

Who owns this facility

Owner / managerTypeRoleSince
LAWRENCE COUNTY NURSING HOME DISTRICTOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/06/1966
BALDWIN, DARRELIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2021
BURKS, DYLANIndividualMANAGING CONTROL - GOVERNING BODYsince 09/01/2024
CHOATE, HIndividualMANAGING CONTROL - GOVERNING BODYsince 06/24/2014
EDEN, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2023
HILTON, KEVINIndividualMANAGING CONTROL - GOVERNING BODYsince 04/01/2021
SPRINGER, MAXIndividualMANAGING CONTROL - GOVERNING BODYsince 04/10/2025
HUSTON, CESSILYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/19/2014
NEWBY, RUSSELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2023
WILLIAMS, CHERYLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
WILLIAMS, TINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2015
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 09/17/2021
MIDWEST PHYSICAL THERAPY PCOrganizationADP OF THE SNFsince 10/01/2019
WHITESELL, SOPHIEIndividualADP OF THE SNFsince 01/23/2023

CMS files one row per role, so the 19 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$5.5M
Net patient revenuemost recent cost report
-8.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 76%Medicare 4%Other / private 20%

About 76% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$251per resident / day
operating cost
$7,616per month
≈ monthly operating cost
$230per day
avg. revenue, all payers

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

What families pay in MO

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265752. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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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