Pleasant View Nursing Home
470 Rainbow Drive,, Rock Port, MO 64482 · For profit - Corporation · 60 certified beds · (660) 744-6252 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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 | 19.8% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.6% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.5% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.5% | 0.0% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 4.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 19.6% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.3% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.1% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.23 | 2.33 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 5.5–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 53.4 residents a day — about 89% occupied, or roughly 7 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 2.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.60 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 2.13 hrs/resident/day on weekends vs 2.52 on weekdays — 15% thinner on weekends. RN hours go from 0.26 to 0.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · E2025-05-22 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for residents (Resident #26 and Resident #47) were correct when the Durable Power of Attorney (DPOA)'s name was printed on the DNR instead of the name of the resident and when the facility failed to ensure the DNR orders for residents (Resident #46 and Resident #47) were not signed by the DPOA prior to the residents being declared incapacitated. This affected three of 13 sampled residents (Resident #26, Resident #46 and Resident #47) The facility census was 51. Review of the facility's policy titled, Advance Directives, dated December 2016, showed: -Advanced directives will be respected in accordance with the state and state law; -Upon admission the resident will be provided with written information concerning the right to refuse or accept treatment; -If a resident is incapacitated and unable to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-22 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 13 sampled residents (Residents #11, #17 and #47). The facility census was 51. The facility did not provide the requested policy on entrapment assessments. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 02/26/25, showed: -Severe cognitive impairment; -Substantial assist for toileting and bathing; -Partial assistance for bed mobility; -Bed rails not used; -Diagnoses included, dementia, other fracture and high blood pressure. Review of the resident's care plan dated, 05/01/25, showed: -Assist of two staff for Activities of Daily Living (ADLs); -Half bed rails to assist with bed mobility; -At risk for falls due to a history of falls. Review of the resident's Physician'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 before2025-05-22 · 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, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 26 opportunities for error which resulted in a medication error rate of 8%, this affected 3 residents of the 13 sampled residents, ( Residents #101, #46, #22). The facility census was 51. Review of the facility's undated Glucose Finger Stick policy, showed: Alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 1. Review of Resident #101's Quarterly MDS, dated [DATE] showed: -Cognition intact; -Requires nursing assistance with self care and mobility; -Diagnoses: Diabetes, high blood pressure, renal insufficiency, parkinsons. Review of the care plan revised on 10/3/24 showed staff are to complete accuchecks two times a day to monitor blood sugar. Observation 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 · E2024-04-10 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 treat residents with dignity and respect when they stood to feed residents who required assistance (Resident #34 and #35) and when they failed to serve residents sitting at the same table at the same time during meal service (Resident #28, #17, #8, and #39. This affected six of twelve sampled residents. The facility census was 48. Review of facility policy, quality of life - dignity, dated August 2009, showed: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. -Residents shall be treated with dignity and respect at all times. -'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 1. Review of Resident #34's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/4/24, showed: -He/She was cognitively intact. -He/She had clear speech; -He/She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · 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 observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to replace trim missing from the base of the nurses station, replace damaged drywall on the side of nurses station, repair the medication cart that had several pieces of black duct tape on top left side, failed to repair a pillar near the left entrance of the dining room which had a 3-4 inch and 1 to 11/2 inch gouges of paint removed and missing paint. The facility failed to keep oxygen concentrators and Continuous Positive Airway Pressure (CPAP) machine dust free when a layer of dust was on Resident #22's oxygen concentrator and CPAP machine. The facility failed to keep Resident #200's dry wall seam was peeling from the ceiling. Additionally the facilty failed to repair a wall at the head of the bed in room [ROOM NUMBER] A that had scuff marks and gouges with the paint missing and white plaster showing. The facility census was 48. Review of facility policy, Quality of Life -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected five of six sampled staff (RN A, [NAME] A, NA A, Maintenance Supervisor, and Care Partner A). The facility census was 48. Review of facility Policy, Abuse and Neglect, dated January 2017, showed: -It is policy to not employe 1) Individuals who have been found guilty by a court of law of abuse, neglect, exploitation, misapprorpiation of property or mistreatment 2) individuals with ahistory of certain criminal offenses 3) individuals on the Employee Disqualification List or who are listed on the state CNA registry as having been found to have committed abuse, neglect, exploitation, or misappropriation of funds, or mistreatment 4) individuals whoa re listed as being (excluded' by the federal DHSS Office of Inspector General or 5) have a disciplinary action in effect against his or her professional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer, the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including he name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman, and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure staff completed a Level I Preadmission Screen and Resident Review (indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI). This affected two of 12 sampled residents, ( Resident #22 and #33). The facility census was 48. Review of the facility's undated policy for PASARR's (Preadmission Screening and Resident Review, a federal requirement to help ensure that individuals are inappropriately placed in nursing [NAME] for long term care) showed: - The Nursing Home Reform Act was passed as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA - 87), and amended by Public Law 100 -203 and 101 - 508, creating the Preadmission Screening and Resident Review ([NAME]) process; - The purpose of the PASARR is to ensure that individuals being considered for admission to a Medicaid certified nursing facility (NF) are evaluated for evidence of possible PASARR conditions (serious…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop and implement a comprehensive person-centered plan of care to include measurable objectives and appropriate timeframe's for five of 12 sampled residents (Resident #3, #6, #22, #34 and #39), when the facilty failed to address Hospice care for one resident (Resident #3), and when the facilty failed to address a pressure ulcer for one resident (Resident #6), and failed to address the use of oxygen and a Continuous Positive Airway Pressure (CPAP, a machine that helps the resident breathe easier) machine for one resident (Resident #22). Additionally, the facilty failed to address the use of cane rails (a device that enables the residnet's mobility) for two residents (Resident #34 and #39). The facility census was 48. Review of the facility's Care Plans, Comprehensive Person-Centered, revised December 2016, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 observations, interviews, and record reviews, the facility failed to ensure staff followed professional standards of care for four of 12 sampled residents (Resident #18, #22. #35 and #46) when staff failed to ensure blood sugars were checked 30 minutes prior to meals which affected two residents (Resident #18 and #35), and failed to obtain a physician's order to check blood sugars for one resident who was receiving insulin (Resident #46) and when staff failed to obtain physician's orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a machine that helps the resident breathe easier) and for changing the oxygen tubing one resident (Resident #22). The facilty census was 48. Review of the facilty's Medication Administration and Maintenance Policy, dated October 2017, showed: -No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed; -No medications will be left unattended or unobserved by 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.
Show the remaining 14 citations
- Potential for harm · E2024-04-10 · 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
Based on observations, interviews and record review, the facility staff failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not ensure nail care was completed for one of 12 sampled residents, (Resident #33) and ensure shaving was completed for two sampled residents, (Resident #3 and #33). The facility census was 48. Review of the facility's undated policy on nail care showed it did not address when fingernail polish should be removed and reapplied. Review of the facility's shaving policy, revised October 2010, showed, in part: - The purpose of this procedure is to promote cleanliness and to provide skin care; - The policy did not address how often a female or male resident should be shaved. 1. Review of Resident #33's care plan, revised 7/1/23 showed: - It did not address how often the resident preferred to be shaved and did not address how often fingernail polish should be removed and reapplied. Review of the resident's quarterly Minimum Data Set (MDS),…
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 before2024-04-10 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete quarterly assessments, and failed to obtain a physician's order prior to installation for two of twelve sampled residents (Resident #22 and #39). The facility census was 48. Facility did not provide a policy on entrapment assessments. Review of facility policy, proper use of side rails, revised December 2016, showed: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. -An assessment will be made to determine the resident's symptoms, risk of entrpament and reason for usng side rails. When used for mobility 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 · Ecited before2024-04-10 · 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 observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (5%). Facility staff made five medication errors out of 25 opportunities for error, resulting in a medication error rate of 20%. This affected four of 12 sampled residents, (Resident #21, #27, #33, and #43). The facility census was 48. Review of the facility's undated policy for medication administration and maintenance, showed, in part: - No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed. Review of the facility's policy for eye drops/ointment administration, dated September, 2017 showed: - Eye drops and eye ointments will be administered according to physician orders and/or recommendations; - Have the resident tilt their head backwards and look up; - Using your finger, hold the eye lid down and apply the drops; - With your finger, apply pressure to the inside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-10 · 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, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, and when the medications were left in pill cups on the dining table for residents in the dining room (Resident #18, #20, and #39) and when the facility failed to discard an opened vial of tuberculin purified protein derivative (skin test used to help diagnose tuberculosis infection), failed to date an opened vial of tuberculin purified protein derivative, and failed to date an opened insulin pen for Resident #46. The facility census was 48. Facility policy, Medication Administration and Maintenance, undated, showed: -No medications will be left unattended or unobserved by Certified Medication Technician or nurse administering to residents. -Self-administration of medication is permitted only if approved in writing by the resident's physician, the resident has been assessed and educated on self-administration 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 · E2024-04-10 · 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 and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot and cold food was not served at an appetizing temperature and when pureed food was not made to proper consistency to three of twelve sampled residents (Resident #22, #39, and #34). The facility had a census of 48. Review of facility policy, general food preparation and handling, undated, showed: -Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Review of facility policy, food temperatures, undated, showed: -All hot foods must be cooked to appropriate internal temperatures, held and served at temperature of at least 135 degrees Fahrenheit (F); -All cold food items must be stored and served at a temperature of 41 degrees F or below; -Temperatures should be taken periodically to assure hot foods stay above 135 degrees…
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 before2024-04-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 48 residents. 1. Review of facility policy, general food preparation and handling, undated, showed: -The kitchen will be kept neat and orderly; -Kitchen surfaces and equipment will be cleaned and sanitized as appropriate; -All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Review of facility policy, food storage, undated, showed: -Food will be stored in an area that is clean, dry and free from…
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 · D2024-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to assist one resident (Resident #6) to maintain hydration status when they failed to provide resident water in his/her room. The facility census was 48. Facility did not provide policy on hydration. 1. Review of Resident #6's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/5/24, showed: -He/She admitted on [DATE]; -Cognition severely Impaired. -He/She required partial/moderate assistance with eating, upper body dressing, rolling left and right, sit to lying, lying to sitting on side of bed -He/She required supervision or touching assistance for oral care; -Diagnoses included pneumonia, high blood pressure, wound infection, thyroid disorder, arthritis, anxiety, and depression. -He/she had mechanically altered diet Review of care plan, dated 2/6/24, showed: -He/She was on a pureed diet with thickened liquids related to decline due to shy draggers syndrome; -He/She would have a water jug handy in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 48. Review of facility policy, Director of Food and Nutrition Services, undated, showed: -The director of food and nutrition services will be responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served. -The Director of food and nutrition services will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that did not have a full time dietician or must designate a person to serve as director of food and nutrition service. During an interview on 4/07/24 at 10:13 A.M., Dietary Manager said: -He/She did not have any dietary certification; -He/She was currently enrolled in college out of state; -He/She did not have any…
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 · D2024-04-10 · 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
Based on observation, record review and interview the facility failed to follow infection control standards and guidelines for catheter care when staff failed to ensure the urinary catheter drainage bag was not touching the floor for one of 12 sampled residents (Resident #3). The facility census was 48. Review of the facility's Urinary Catheter Care Policy, dated September 2014, showed: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -Use standard precautions when handling the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facilty's Infection Prevention and Control Policy dated September 2023, showed: - The facilty will establish a safe, sanitary and comfortable environment to help prevent the development and transmission of infections for all residents; -Standard precautions will be used for all resident care; -Staff will properly handle and clean and disinfect resident equipment. 1. Review of Resident #3's quarterly minimum data set (MDS), a federally mandated assessment tool completed…
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 before2023-02-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to prepare and serve food under sanitary conditions when staff failed to change gloves between dirty and clean tasks, failed to date opened food products and failed to store clean dishes in a manner to protect them from possible contamination from food and dust. This had the potential to affect all the residents who ate in the facility. The facility census was 42. Review of the undated general food preparation and handling policy showed: - Disposable gloves are a single use item and should be discarded after each use; - Employees should wash hands prior to putting gloves on and after removing gloves; - Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: *After coughing or sneezing into hands, using a handkerchief or tissue, using tobacco or touching hair or face; *After handling garbage or garbage cans; *After handling soiled trays or dishes; *After handling anything soiled; *After handling boxes, crates or packages;…
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 · D2023-02-08 · 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
Based on interview and record review, the facility failed to provide at least two days notice of benefits end date for two of three residents sampled for beneficary notices (Resident #8 and #148) when changes were made to their Medicare coverage prior to the end of service date. The facility had a census of 42. The facility did not provide a policy. 1. Review of Resident #8's Skilled Nursing Beneficiary Protection Notification (SNBPN) Review (SNBPN) form showed: - Medicare Part A Skilled Services Episode Start Date: 12/8/22; - Last covered day of Part A Service: 12/22/22 - (Part A terminated/denied or resident was discharged ); - The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted; - The resident's representative signed the form on signed on 12/22/22, the last day of services. 2. Review of Resident #148's SNBPN form showed: - Medicare Part A Skilled Services Episode Start Date: 9/23/22; - Last covered day of Part A Service: 10/12/22 - (Part A terminated/denied or resident was discharged ); - The facility initiated the discharge…
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 · D2023-02-08 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 they put a discharge planning process in place which addressed goals and needs, including caregiver support and referrals to local contact agencies, as appropriate and involved the resident and if applicable, the resident representative and interdisciplinary team in developing a discharge plan for one of two residents sampled for closed record review (Resident #44). The facility census was 42. Record review of the Discharge Planning Policy, dated September 2017, showed: - It is the policy to complete discharge planning on any resident where discharge is anticipated to home, another SNF/NF or other type post-acute setting; - Discharge planning is a patient-centered interdisciplinary process that begins with an initial assessment of the resident's potential needs at the time of admission and continues throughout the resident's stay. - Residents and representatives should be informed of the appropriate community resources available and encouraged to participate in the discharge planning process. 1. Review of 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 · D2023-02-08 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility staff failed to complete a comprehensive discharge summary for one of two residents sampled for discharge planning (Resident #44). The facility census was 42. Review of Discharge Policy dated September 2017 showed the discharge summary will include but is not limited to, the following: - Recapitulation of the resident's stay including, but not limited to diagnosis, course of illness/treatment or therapy, pertinent lab, radiology and consultation results. - Final summary of the resident's status at discharge. This summary will be available for release to authorized individuals and agencies with the consent of the resident or the resident's legal representative. The following items are required to be in the final summary of the resident's status: *Identification and demographic information *Customary routine *Cognitive patterns *Communication *Vision *Mood and behavior patterns *Psychosocial wellbeing *Physical functioning and structural problems *Continence *Disease diagnoses and health condition *Dental and nutritional status *Skin…
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 · D2023-02-08 · 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 observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring one of 12 sampled residents (Resident #12) during a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or reposition) transfer, during the use of a mechanical lift transfer for one sampled resident (Resident #33) and when staff used one sampled residents' (Resident #30) pants to reposition the resident in his/her wheelchair. The facility census was 42. 1. Review of the facility's policy for mechanical lift, dated January 2017, showed in part: - All transfers of residents requiring full-body mechanical lifts will be made by two nursing staff persons; - Staff will lock the resident's wheelchair brakes and spread mechanical lift base of support for stabilization prior to transfer; - One staff member will operate the controls to the mechanical lift while second staff member stands by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BLUE SKY BASIN, LLC — 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 | 1.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 1.8 | +2.2 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 1.4 | +0.6 vs chain |
The other 4 homes this chain runs (chain average 1.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GATEWAY MO2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2022 |
| SLOANS LAKE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 63% | since 12/01/2022 |
| TWYMAN, MEGAN | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2022 |
| BERGER, ELIOT | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
| PERLOW, BERNARD | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
2 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.
This home reported $142K 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 265744. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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.