Katy Manor
205 Prospect, Pilot Grove, MO 65276 · Government - County · 60 certified beds · (660) 834-3111 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.4% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.9% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.8% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.1% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.6% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 23.9% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.2% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.3% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.8% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.1% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.8% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.40 | 2.11 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.44 | 2.33 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.2% 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.
Met the expected recovery: 58.6% 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 29 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 0.18 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.2%CMS range 25.1–52.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.6–17.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.6% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 58.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.6% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 97.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 3.8–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.66 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 56.9 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs fairly full. 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 2.87 hrs/resident/day on weekends vs 3.72 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.60 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · Dcited before2025-03-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to transcribe a wound treatment order for one resident (Resident #2) and failed to obtain an order for Lyrica upon admission for one resident (Resident #156). The facility census was 47. 1. Review of the facility's Wound Treatment Management Policy, undated, showed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 02/26/25, showed staff assessed the resident as follows: -Substantial/maximal assistance with lower body dress, and put on/off footwear; -Partial/moderate assistance with sit to lying, and sit to stand; -Resident at risk for pressure ulcer; -No suspected deep tissue injury. Review of the resident's nurses note, dated 03/20/2025 at 12:35 P.M., showed the Assistant 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.
- Potential for harm · Dcited before2025-03-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to remove and destroy expired tube feedings and intravenous (IV) supplies from one of one medication storage room, and failed to discard expired insulin from one of one sampled insulin storage cart. The facility's census was 47. 1. Review of the facility's policy titled, Medication Storage, undated, showed the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. 2. Observation on 03/24/25 at 9:38 A.M., showed the medication storage room contained: -24 cartons of Jevity 1.2 Calories/8 Fluid oz (ounce) (a fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long or short-term tube feeding) with an expiration date of 01/11/25; -Four IV primer tubing kits for infusion pump (used to administer fluids, medications, and nutrients directly into a vein) 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.
- Potential for harm · D2025-02-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to notify one resident's (Resident #1) physician after a significant medication error. The facility census was 56. 1. Review of the facility's Notification of Change policy, undated, showed staff are directed to promptly consult the resident's physician when there is a change requiring notification. This includes adverse drug reaction and potential to require physician intervention. These may include adverse consequences, acute condition and exacerbation of chronic condition. The primary physician will be notified regardless of whether the resident is receiving Hospice Services. 2. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/29/24, showed staff assessed the resident received opioid seven days of the seven day look back period. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed a physician order for Fentanyl 25 micrograms (mcg)/per hour and change every 72 hours. Review of the resident's Medication Administration Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from significant medication errors, when facility staff administered double the prescribed dosage of Fentanyl to the resident. The census was 56. 1. Review of the facility's Medication Administration policy, undated, showed staff are directed as follows: -Ensure right dosage, right time and right documentation; -Review Medication Administration Record (MAR) to identify medication to be administered; -Administer within 60 minutes prior to or after scheduled time; -Sign MAR after administered; -If medication is a controlled substance, sign narcotic book; -Correct any discrepancies and report to nurse manager. 2. Review of the facility's Controlled Substance policy, undated, showed staff are directed as follows: -The controlled drug record serves the dual purpose of recording both narcotic disposition and patient administration; -Two licensed staff must witness any disposal or destruction of a controlled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to meet professional standards when staff did not obtain orders for catheter care for three residents (Resident #1, #2, and #3) out of three sampled residents, and did not obtain orders for a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall) and colostomy care for one resident (Resident #3) out of one sampled resident. The facility census was 53. 1. Review of the facility's Medication and Treatment Orders Policy, undated, showed medications, treatments, and care tasks shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's Routine Catheter Care Policy, undated, showed catheter care is to be provided once a shift and as needed. Catheters and drainage bags are to be changed every month and as needed. This order will be placed in the chart by the admitting nurse or nurse who has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-16 · tag F0678 — failed to provide CPR when needed — isolatedProvide 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, facility staff failed to ensure one resident (Resident #1) out of three sampled residents code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was documented correctly throughout the medical record. The facility census was 54. 1. Review of the facilty's resident rights policy, dated 2022, showed staff are directed as follows: -Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -Each resident has the right to choose health care services consistent with his or her interests. Review of the facility's Advanced Directive policy, dated 2020, showed staff are directed as follows: -An advanced directive is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the residents environment remained free of accident hazards when staff failed to store hazardous chemicals, safely propel one resident (Resident #34) in a wheelchair, lock unattended medication carts, and provide safe mechanical lift transfers for two residents (Resident # 5, and #14). The facility census was 51. 1. Review of the facility's policy titled, Hazardous Chemical Inventory Listing, revised April 2013, showed staff are directed to the following: -A hazardous chemical is any chemical which is classified as a (an): -Physical hazard; -Health hazard; -Simply asphyxiant; -Combustible dust; -Pyrophoric gas; -Hazard not otherwise classified. 2. Observation on 11/30/23 at 8:42 A.M., showed the housekeeping cart unattended and unlocked on the 100 hallway. The cart contained a bottle of toilet bowl cleaner on top of the cart with resident's nearby. During an interview on 11/30/23 at 8:43 A.M., Housekeeper N said the toilet bowl…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain a medication error rate less than five percent (%) out of 37 opportunities observed, 24 errors occurred, which resulted in a 64.8% error rate which effected five resident's (Resident #7, #12, #17, #18, and #42) of the five sampled resident's. The facility census was 51. 1. Review of the facility's Administering Medications policy, undated, showed the Director of Nursing (DON) Services supervises and directs all personnel who administer medications. Review showed: -Medications are administered in accordance with prescribed orders, including any time frame; -Medication administration times are determined by the resident need and benefit, not staff convenience; -Medication errors are documented, reported, and reviewed by Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and/or the need for additional staff training; -Medications are administered within one hour of their prescribed time.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage rooms, and one of one medication carts. The facility census was 51. 1. Review of the facility's policy titled, Storage of Medications, undated, showed staff were directed as follows: -Drugs and biological's shall be stored in the packaging, containers or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Compartments (including, but not limited to , drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to maintain professional standards of documentation when staff failed to complete weekly skin assessment per physican orders for one residents (Resident #3) and failed to ensure safe medication administration for three residents (Resident #18, #31, and #35). The facility census was 51. 1. Review of the facility's Skin Ulcer-Wound policy, undated, showed: -All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations; -Measurements must be completed weekly by the same licensed person when at all possible; -A wound assessment should be documented in the nurse's notes (or other documentation location) with each dressing change. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/10/23, showed staff assessed the resident as: -Cognitively intact; -At risk for developing pressure wounds; -Had moisture associated skin damage (MASD); -Had applications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · F2022-10-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility staff failed to ensure the ice machine drained through an air gap. Facility staff also failed to thaw meat in a manner to prevent the growth of food-borne pathogens and food-borne illness. The facility census was 51. 1. Review of the facility's Policy for Care and Maintenance of Ice Machine, undated, showed staff were directed to check the drain line weekly and clean as needed. Observation on 10/4/22 at 11:50 A.M., showed an outside company technician serviced the ice machine. Further observation showed the ice machine drained into the floor drain without an air gap. The ice machine drainpipe contained a black substance on the lower quarter inch of the pipe which hung below floor level. During an interview on 10/4/22 at 11:52 A.M., the service technician said the ice storage bin did not drain and water backed-up into the ice storage area. He/she said the ice machine should drain through a gap into the floor drain. The service technician said the drainpipe should not contain any black substances. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-06 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and nail care, change dirty clothing, and provide showers to seven residents (Residents #24, #28, #32, #34, #35, #40, #42, #198). The facility census was 51. 1. Review of the facility's Policy for Activities of Daily Living, dated January 2019, showed: -ADLs refers to the residents' daily self-care activities. The ability or inability of the resident to perform ADLs is a measurement of their functional status; -A resident who cannot perform essential ADLs may have poorer quality of life or be unsafe in their environment; -Residents will be assisted with ADLs as needed based on their functional status; -Common ADLs include eating, bathing, dressing, grooming, toileting and mobility. 2. Review of Resident #24's Annual Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-10-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure razors/sharps and hazardous chemicals were stored in a safe manner, and failed to lock an unattended treatment and medication cart. Additionally, staff failed to properly propel an unidentified resident and one additional resident (Resident #9) in wheelchairs in a manner to prevent accidents, and failed to safely transfer three residents (Resident #1, #26, and #28). The facility census was 51. 1. The facility did not provide a Hazardous Chemicals/Sharps Storage Policy. Observation on 10/6/22 at 7:05 A.M., showed 300 hall Spa unlocked and unattended as residents walked down the hallway and sat in the day room. Further observation showed an unlocked and unattended cabinet that contained: -Two pairs of scissors; -One can of Ultrasure Deodorant spray, labeled Contact Poison Control if ingested; -One container of Sani-Cloth Germicidal Wipes, labeled Contact Poison Control if ingested; -Three razors; -One bottle of Nystatin powder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-06 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, facility staff failed to follow their Facility-Wide assessment to ensure a sufficient number of qualified staff were available to meet the needs of their residents. Additionally, facility staff failed to review and update the assessment when their resident population increased from 37 to 51. The facility census was 51. 1. Review of the facility's Facility-Wide Assessment, dated 3/1/22, showed staff documented the assessment occurred with a census of 37 residents. Additionally, staff documented the following staff requirements to meet the needs of the residents: -Day Shift: -Three Registered Nurses (RN); -Two Licensed Practical Nurses (LPN); -Six Nurse Aides (NA); -One Restorative Aide (RA); -One Certified Mediation Technician (CMT); -Night Shift: -One LPN; -Three NA's. 2. Review of the facility's Daily Staff Posting's, dated September 2022, showed staff documented the working shift hours as Day Shift 7:00 A.M., to 7:00 P.M., and Night Shift 7:00 P.M., to 7:00 A.M. Additionally staff documented: -9/1/22: Census- 51; -Day Shift: --One RN; --Four…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Resident #1 and #28). Additionally, facility staff failed to clean a mechanical lift (mechanical device used to lift and transfer a resident) between resident uses. The facility census was 51. 1. Review of the facility's Hand Hygiene Policy and Procedure, dated March 2020 showed the purpose is to reduce the risk of the incidence of Healthcare-associated infections. Further review showed: -Indications for handwashing and hand rubbing include: -When hands are visibly dirty or are visibly soiled with blood or other bodily fluids; -After contact with a resident's intact skin; -After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled; -When moving from a contaminated body site to a clean body site during resident care; -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-06 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, staff failed to provide necessary behavioral health services and/or contact the physician to support one resident's (Resident #49) psychosocial well-being after the resident had voiced concerns with new hallucinations and depression, and when the resident's family member voiced concerns to staff in regard to the resident's mental status and history of self harm. The facility census was 51. 1. Review of the facility's Notification of Physician policy, dated September 2017, showed: -It is the policy of the facility that they must immediately inform the resident's physician when there is an accident/incident involving the resident which results in injury and has the potential for requiring physician intervention and a significant change in the resident's physical, mental or psychological status (i.e. significant change in mood or behavior); -Immediately means as soon as possible, but ought not to exceed 24 hours after discovery of the incident. Review of the facility's Behavioral Health Services policy, undated, showed: -Behavioral symptoms will 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COOPER COUNTY NURSING HOME DISTRICT NO 1 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/15/2010 |
| AGGELER, LYLE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/24/2010 |
| BEACH, LAURIE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 05/01/2016 |
| GERLING, MARILYN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 10/01/2014 |
| HIRST, JUDI | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 04/12/2016 |
| LORENZ, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 05/01/2016 |
| TWENTER, HERBY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/11/2006 |
| MCKINNEY, CARRIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2022 |
| PEECHER, CARRIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| RANSBURGH, DANIELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/28/2024 |
| TWENTER, KENDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/10/2024 |
CMS files one row per role, so the 27 rows in the source record cover these 11 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.
This home reported $14K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265801. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, 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.