Foxwood Springs Living Center
1500 West Foxwood Drive, Raymore, MO 64083 · For profit - Limited Liability company · 108 certified beds · (816) 331-3111 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,627 in federal fines (most recent 2024-02-06)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 34.9% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.6% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.0% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.4% | 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 | 4.3% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 32.3% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.1% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.1% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.1% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.7% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.3% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.14 | 2.11 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.59 | 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.
57.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 217 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.7% 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 141 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.4%CMS range 51.9–63.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.6–14.6 | 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 | 61.7% | 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 | 61.7% | 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 | 50.4% | 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 | 93.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.6% | 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 | 5.0%CMS range 3.2–8.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 108 beds and averages 91.4 residents a day — about 85% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.28 hrs/resident/day on weekends vs 3.62 on weekdays — 9% thinner on weekends. RN hours go from 0.55 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2024-02-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect one sampled resident (Resident #3) out of 10 sampled residents from intimidation and physical abuse. On 1/25/24 at about 10:00 A.M., Licensed Practical Nurse (LPN) A, Certified Nurses Aide (CNA) A, CNA B, and CNA C forcibly made the resident shower. The resident said no and struck out at staff. The resident reported having a fear of water and doesn't like water on his/her face. The resident was visibly tearful and upset while recounting the event. The resident had a thumb size dark purple bruise with a green ring around it on the back of his/her right upper arm, thumb size dark purple bruise on the left lower arm below the elbow, and finger size dark purple bruise on the right upper outer arm. The facility had 87 residents. On 2/5/24 at 2:35 P.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 1/25/24. On 1/30/24, facility administration was notified of the incident, an…
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 before2025-10-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician's order for a narcotic medication was accurately shown on the narcotic sheet and Medication Administration Record (MAR); failed to ensure the nurse accurately documented narcotic medications administered on the MAR; and failed to ensure the policy and procedure for corrections made on the narcotic sheet were followed for one sampled resident (Resident #4) out of 8 sampled residents. The facility census was 92 residents. Review of the facility's Administering Oral Medication policy and procedure dated October 2010, showed the purpose was to provide guidelines for safe administration of oral medications. The policy showed the staff should:-Verify that there is a physician's order for the medication.-Place the MAR within easy viewing distance.-Unlock the medication cart and select the drug from the unit dose drawer.-Check the label on the medication and confirm the medication name and dose with the MAR.-Check 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 · Fcited before2025-01-10 · 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to clean the kitchen floors, preparation table, shelves and drawers, stove, the grill, grill area, ovens, sides and front of the deep fat fryer, refrigerators, and the steamer/convection ovens. Findings include: Review of the undated Sanitization policy read in part: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and implementation - 1. All kitchens, kitchen areas and dining areas shall be kept clean . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot…
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 · F2025-01-10 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to maintain a Quality Assessment and Performance Improvement (QAPI) Committee with the participation of the Medical Director and Infection Control Preventionist (or designee) for three (3) out of six (6) quarterly meetings. Findings include: Review of the facility's Quality Assurance and Performance Improvement policy, dated 3/15/24, noted, Policy Interpretation and Implementation . 5 . The following individuals serve on the committee: Administrator, or designee who is in a leadership role; Director of Nursing Services; Medical Director; Infection Preventionist . Review of QAPI committee meeting attendance sheets revealed all required committee members signed the attendance sheets for meetings held on 9/21/23, 3/21/24, and 6/20/24. On 12/21/23, the signature of the Medical Director was not present on the sign-in sheet for this quarterly meeting. On 9/19/24, the signature of the Infection Control Preventionist was not present on the sign-in sheet for this quarterly meeting. On 12/19/24, the signatures for both the Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility's cleaning checklist, the facility failed to maintain the physical environment in a safe, clean, comfortable and homelike manner on 200 Hall for two (2) residents who resided on this hall (Resident #48 and Resident #53), and failed to maintain in a safe, clean manner a lounge area and ice machine shared by residents from both 100 and 200 Halls. The combined census on the 100 and 200 Halls on 1/7/25, the first day of the survey, was 45. Findings include: During the initial tour of 200 Hall on 1/7/25, beginning at 12:55 p.m., observation found the carpeting on the hall was not clean, with small pieces of paper trash, small fragments of gauze, and debris noted throughout the length of the hallway from one (1) end of the residential corridor to the other. The carpeting on this hall was found to be in the same state when observed throughout the rest of the afternoon on 1/7/25 and throughout the day on 1/8/25. An observation was made of Resident #48's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-10 · 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
Based on observation, interview and record review, the facility staff failed to ensure an environment free from accident hazards. Staff failed to secure the contents of an unattended treatment cart stored in a lounge used by residents on the 100 and 200 Halls. The cart contained medicated creams, ointments, and topical sprays, as well as bandage scissors. The unlocked treatment cart presented a potential hazard to all residents residing on 100 and 200 Halls. Findings include: Review of the facility policy titled Security of Medication Cart, revised April 2007, noted: Policy Interpretation and Implementation . 4. Medication carts must be securely locked at all times when out of the nurse's view. On 1/7/25 at 12:41 p.m., the surveyor observed an unlocked treatment cart in which were stored band aids, bandages, gauze, gauze tape, lidocaine pain spray, medicated ointments and creams, and bandage scissors. The cart was stored in an open lounge area, and multiple residents were observed to be within six (6) feet of the treatment cart. In an interview on 1/7/25 at 12:42 p.m., Registered…
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 · D2025-01-10 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident, who was not determined by a physician to lack the ability to make informed healthcare decisions, was provided with opportunities to make decisions in their best interest for the Care Plan process. This was evidenced by one (1) of three (3) residents sampled for participation in the Care Plan process (Resident #64). Findings include: Review of the facility's Advance Directives policy with a revision date of December 2016 revealed: Policy Statement - Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation . 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above,…
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 · D2025-01-10 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident. This was evidenced for one (1) of three (3) residents sampled for Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Resident #64). Findings include: Review of Resident #64's Durable Power of Attorney (DPOA) for Health Care Decisions documents revealed, I appoint the person named below to be my agent to make health care decisions for me when and only when I cannot make decisions or communicate what I want done. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. In an interview on 1/10/25 at 4:25 p.m., Social Worker #1 stated that Resident #64 was not notified of the determination of non-coverage, because 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 · D2025-01-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to develop a Comprehensive Care Plan after a significant change in the status/condition of a resident. This was evidenced by Resident #10 having had an unwitnessed fall with major injury resulting in a right hip replacement and pubic bone fracture on 7/24/24. The Care Plan was not revised within seven (7) days to ensure timeliness of a person-centered comprehensive assessment to address the resident's needs for one (1) of one (1) resident sampled for Comprehensive Care Plan timeliness (Resident #10). Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022, noted: Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Review of Resident #10's face sheet documented an admission date of 2/1/21. Medical 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.
- Potential for harm · D2024-07-09 · 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, the facility failed to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident (Resident #2) out of three sampled residents. The facility census was 88 residents. The Director of Nurses (DON) and the Administrator were notified on 7/9/24 of Past Non-Compliance which occurred on 5/10/24. All nursing staff were in-serviced on notification of responsible parties on 6/21/24. The deficiency was corrected on 6/21/24. Review of the facility's policy titled Charting and Documentation dated July 2017 showed: -Any changes in the resident's condition shall be documented in the resident's medical record. -Documentation should include notification of the family. 1. Review of Resident #2's undated admission record showed the resident had a Durable Power of Attorney (DPOA) and had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning, and personality changes). Review of the resident's care plan dated 2/10/23 showed: -The resident had dementia.…
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 before2024-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide safe transfer assistance for one sampled resident (Resident #3). On 1/25/24 the resident was transferred by four staff from his/her wheelchair to a shower chair without the use of a gait belt, while the resident physically resisted. Staff grabbed the resident by his/her arms and lifted him/her up from the wheelchair, resulting in bruising on the back of his/her right upper arm, left lower arm below the elbow, and on the right upper outer arm. The facility census was 87 residents. Review of facility policy Safe Lifting and Movement of Residents, revised 7/2017, showed: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents. -Residents safety would be incorporated into goals and decisions regarding the safe lifting and moving of residents. -Nursing staff, in conjunction with the rehabilitation staff, would have assessed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Fcited before2023-07-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to place the date on the tray of when the turkey breasts and chicken pieces were taken from the freezer for defrosting; to remove encrusted deposits of burnt-on debris from the stove top; to refrigerate items (dessert toppings, steak sauce, grape jelly); to protect several glasses of juice and plates of apple crisp from a dusty fan in the [NAME] Bridge dining room; to maintain the fans the [NAME] Bridge Kitchenette free from a heavy buildup of dust; failed to measure the temperature of non-pasteurized eggs before they were placed on a plate for service; and to remove debris from the nozzles of the spray wand of the automated dishwasher. This practice potentially affected 80 residents who ate food from the kitchen. The facility census was 80 residents. 1. Observation on 6/26/23 at 8:52 A.M., during the initial kitchen observation showed two turkey breasts and a bin of frozen chicken pieces were taken from the freezer and did not have a date that showed when…
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 · E2023-07-03 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed-hold form was completed and sent for three sampled residents who were discharged to the hospital (Resident #3, #7 and #328) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Bed-Holds and Returns dated March 2022 showed: -All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). -Residents are provided written information about these policies at least twice: --Well in advance of any transfer (in the admission packet). --At the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #328's face sheet showed he/she admitted to the facility with the following diagnoses of Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily…
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 · E2023-07-03 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain hot foods at or close to 120 ºF (degrees Fahrenheit) for two sampled residents (Residents #35 and #43) who received room trays on 6/29/23. This practice potentially affected at least four residents who received room trays on that date. The facility census was 80 residents. 1. Review of Resident #43's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 5/24/23, showed the resident had moderate cognitive impairment. During an interview on 6/29/23 at 8:58 A.M., Certified Nursing Assistant (CNA) A said he/she worked 3 to 4 days per week and had not seen anyone from the dietary department go out to the hallways to measure the food temperatures. Observation on 6/29/23 at 9:12 A.M., showed: -A room tray was delivered to the nurse's station for the resident. -At 9:17 A.M. CNA A took the resident's tray to his/her room. Observation on 6/29/23 at 9:18 A.M during…
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 · E2023-07-03 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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, the facility failed to do or maintain the following area in a clean, sanitary or comfortable manner: maintain the ceiling vents in the employee breakroom, free of a buildup of dust; ensure the screen over the outdoor vent in the laundry room was completely secured to the wall to prevent the entrance of pests; to maintain the commode seat in resident room [ROOM NUMBER], without any indentations; to ensure there was negative air flow in the shower rooms and the restrooms of the resident rooms on the 600 Hall; to maintain the ceiling vent without a heavy buildup of dust in the 800 Hall shower room; and to maintain the [NAME] Bridge kitchenette at a comfortable temperature during the breakfast meal preparation on 6/29/23. This practice affected no-resident areas (the employee breakroom and the [NAME] Bridge Kitchenette) and at least 4 residents on the 600 Hall. The facility census was 80 residents. 1. Observation on 6/27/23 at 10:59 A.M., with Maintenance Worker B showed a heavy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supporting documentation for the use of a wandering type bracelet (are monitoring devices that are attached to patients and electronically notify nurses when the patient attempts to leave the ward or unit to which the patient is assigned) safety device to include changes in resident behavior, or exit seeking behaviors for one sampled resident who was his/her own responsible person and who's Brief Interview for Mental Status (BIMS) score was 15 (A score of 13 to 15 would indicate the resident was cognitively intact); and to document the resident's right to consent either verbal or written consent, for the use of a wandering safety device for one sampled resident (Resident #16); and to allow one sampled resident (Resident #37) who was cognitively intact the ability to make decisions for himself/herself out of 19 sampled residents. The facility resident census was 80 residents. Review of the facility Wander and Elopements Policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 the privacy of one sampled resident (Resident #4) during a blood glucose test (a test that measures the amount of glucose (sugar) levels in the blood) and when receiving insulin (a hormone produces in the pancreas which regulates the amount of sugar in the blood) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Dignity dated February 2021 showed staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses: -Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age due to degeneration of the brain) with Early Onset (having an age of onset of Alzheimer's younger than [AGE] years old). -Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · 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
Based on observation, interview, and record review, the facility failed to follow professional standards by not aspirating (draw fluid by suction) or flushing an peripheral intravenous catheter (PIVC or IV-a thin plastic tube inserted into a vein using a needle) prior to administering medication for one sampled resident (Resident #278) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy, titled Dispensing and Administration of Saline and Heparin Flushes for IV Catheters dated February 2017, showed staff were required to flush any type of IV catheter: -With 10 milliliters (ml) of Normal Saline (a sterile solution that is a mixture of sodium chloride and water) prior to administering medication through the IV. -With 10 ml of Normal Saline after administration of any medication through the IV. Review of the facility's policy titled Peripheral Intravenous Catheter Flushing dated 2021 showed: -Staff were to obtain, document, and submit to the pharmacy, orders for a PIVC to be flushed. -Staff were required to flush a PIVC to ensure and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the wheels on all mobile devices were locked prior to transferring and repositioning one sampled resident (Resident #278) out 19 sampled residents. The facility census was 80 residents. A copy of the facility's policy on accidents and transferring of residents was requested and not received at the time of exit. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Abnormalities of gait and mobility. -Muscle Weakness. -Fall from chair. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/25/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of six, indicating the resident had severe cognitive impairment. -Extensive staff assistance was required for bed mobility. -Extensive staff assistance was required for transferring from one surface to another. Review of the resident's care plan, last revised 6/28/23, showed: -Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a suprapubic (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter (flexible tube) was monitored, cleaned as ordered, and that an assessment of the resident's ability to perform the task had been completed, for one sample resident (Resident #20) out of 19 sampled residents. The facility census was 80 residents. The facility's policy for self-care of catheters was not received at time of exit. Review of the facility's policy, dated October 2010, titled Suprapubic Catheter Care showed staff were to: -Observe urine for any unusual appearance. -Check the resident frequently to ensure tubing was free of kinks. -Empty the collection bag. -Observe the stoma (a surgically made hole) for redness or skin breakdown. -Document the characteristics of the urine and skin after care was performed. Review of the facility's policy, dated February 2021, titled Self-Administration of Medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #278) was free from unnecessary medications by ordering and administering an incorrect medication multiple times, out 19 sampled residents. The facility census was 80 residents. Review of the facility's Medication Therapy policy, dated April 2007, showed each resident's medication regimen was to include only medications necessary to treat existing condition. Review of the facility's undated policy titled General Guidelines for Transcribing Orders onto the Medication Administration Record (MAR) showed staff were to transcribe the information as it was written on the order. Review of missouricareereducation.org's undated Certified Medication Technician Student Manual, Lesson Plan 6, Transcribing Physician's Orders-General Principles showed: -All transcriptions were to be error-free. -Staff were to verify medication orders by writing them down and reading them back to the physician. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #278), out of 19 sampled residents, was free from a significant medication error by administering the incorrect antibiotic for three days. The facility census was 80 residents. Review of the facility's Medication Therapy policy, dated April 2007, showed each resident's medication regimen was to include only medications necessary to treat existing condition. Review of the facility's undated policy titled General Guidelines for Transcribing Orders onto the MAR (Medication Administration Record) showed staff were to transcribe the information as it was written on the order. Review of missouricareereducation.org's undated Certified Medication Technician Student Manual, Lesson Plan 6, Transcribing Physician's Orders-General Principles showed: -All transcriptions were to be error-free. -Staff were to verify medication orders by writing them down and reading them back to the physician. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-03 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 offer and provide dental services for one sampled resident (Resident #37) out of 19 sampled residents. The facility census was 80 residents. The facility did not provide a copy of their dental policy at time of exit. 1. Review of Resident #37's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). -Dysphagia (difficulty swallowing). Review of the resident's admission Note, dated 1/16/23, showed Licensed Practical Nurse (LPN) A documented: -The resident had no teeth. -Broken or ill-fitting dentures were not assessed. -Abnormal mouth tissue was not assessed. -Lack of natural teeth was not assessed. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/23/23, showed staff assessed the resident and documented 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 · D2023-07-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to use adequate handwashing to prevent cross contamination during resident care for one sampled resident (Resident #45); to ensure the intravenous (IV-a medical technique that administers fluids, medications and nutrients directly into a person's vein) medication tubing's luer connector (the male end of the IV tubing that is inserted into the female end of an IV line that has been placed in a person's vein to form a secure yet detachable leak-proof connection) remained sterile while administering IV antibiotics; and to ensure supplies were placed on a barrier for one sampled resident (Resident #278) out of 19 sampled residents. The facility census was 80 residents. The facility's policy and procedure for administering IV fluids was requested and not received at time of exit. Review of SimpleNursing.com's article, dated 6/6/22, titled How to Start an IV showed staff were to: -Hang the IV bag from something elevated and fill the tubing 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 · Ecited before2021-10-29 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure narcotic counts were completed and signed by two staff each shift for five medication carts and three medication rooms. The facility census was 84 residents. Record review of the facility's Controlled Substance policy dated 4/2019 showed: -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. -Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. -The Director of Nursing (DON) investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. 1. Record review of the 100 and 200 hall medication room Eight Hour Verification of Controlled Substances Count showed: -One sheet was used for both the 100 and 200 hall medication room narcotic storage from 8/1/21 - 9/11/21. -The narcotic count record dated 8/1/21 - 8/21/21 showed two staff did not sign the on-coming or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-10-29 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure multi-dose medications were dated when opened, including insulin pens and liquid narcotics. The facility census was 84 residents. Record review of the facility's Medication Storage Guidance dated April 2019 located in a medication room showed: -Multidose vials for injection (not specifically mentioned elsewhere): Date when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. -Tuberculin: Date when opened and discard unused portion after 30 days. -Ativan oral solution: If kept in the refrigerator, date when opened and discard 90 days after opening. -Novolog: good for 28 days after opening. -Lantus: good for 28 days after opening. Record review of the Storage of Medications policy dated November 2020 showed: -The nursing staff is responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. -Discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. 1. Observation on 10/27/21 at 8:41…
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 · D2021-10-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a coordination of care with hospice (end of life care) for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 84 residents. 1. Record review of Resident #31's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Anaplastic large cell lymphoma (a cancer of the lymph system, part of our immune system). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbances. Record review of the resident's Order Summary Report (OSR) showed on 11/24/20 to admit to hospice services for a diagnosis of senile degeneration (mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). Record review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure behaviors were documented when a resident has increased behaviors to warrant the use of a Pro Re Nata (PRN-as needed) anti-anxiety medication (a controlled substance medicine that calm and relax people with excessive anxiety, nervousness, or tension), and to document non-pharmacological interventions (any sort of intervention not directly involving a medication) prior to the administration of a PRN anti-anxiety medication for one sampled resident (Resident #12) out of 12 sampled residents. The facility census was 84 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring revised 3/2018 showed: -The facility would provide residents with behavioral health services as needed to maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. -The nursing staff would identify and document the specific details about the changes of the mental status,…
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 · D2021-10-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 30 observed medication opportunities, five errors occurred resulting in an error rate of 16.67%. Facility staff crushed medications not approved for crushing for one resident (Resident #9) and to apply pressure to the corner of the eye following administration of eye drops for one resident (Resident #77). The facility census was 84 residents. Record review of ophthalmioprofessional.com, September 2013 issue Administering Eye Medication showed: - Applying light pressure on the inner canthus (the inner or outer corner of the eye, where the upper and lower lids meet) for one or two minutes while keeping the eyes closed prevents the absorption of medication systemically. -This procedure is especially useful if the resident complains about the taste of the medication, if absorption of the medication may result in harmful systemic (relating to or affecting the body as a whole)…
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
$13,627 in federal fines across 1 penalty.
- $13,627 — penalty dated 2024-02-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to BONCREST RESOURCE GROUP — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 3 of 5 | 3.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 3.8 | -0.8 vs chain |
The other 4 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BONCREST RESOURCE GROUP INC | Organization | DIRECT OWNERSHIP INTEREST | since 08/01/2021 |
| RAYMORE HEALTHCARE INVESTORS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 08/01/2021 |
| BAKER, AMELIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 11/10/2023 |
| CORRIGAN, FRANK | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/01/2021 |
| MATHENY, CYNTHIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2022 |
| PAYNE, OREN | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/01/2021 |
| ROSENBAUM, MAURICE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 08/01/2021 |
| OAKDALE SENIORS ALLIANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2022 |
| GEHA, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2023 |
| MINTER, DERRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/15/2024 |
| OMWOHA, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/18/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 11 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265803. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-10, 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.