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Laurel Meadows Wellness & Rehabilitation

723 1st CAPITOL DRIVE, Saint Charles, MO 63301 · For profit - Limited Liability company · 103 certified beds · (636) 946-4140 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 20242 immediate-jeopardy citations$11,536 in federal fines
Insights

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

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $11,536 in federal fines (most recent 2023-11-13)
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
400 1st Capitol Dr · (636) 255-3003 · Call to confirm hours
Pharmacy
488 S 5th St · (636) 949-5593 · Call to confirm hours
Grocery
117 S Main St · (636) 395-7290 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
801 1st Capitol Dr · (636) 947-0066

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.8%18.1%15.4%better
Long-stay residents who lose too much weight1.0%5.3%5.4%better
Long-stay residents with a catheter left in their bladder4.6%1.1%0.9%worse
Long-stay residents with a urinary tract infection4.4%2.3%2.0%worse
Long-stay residents with depressive symptoms4.1%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.2%4.1%3.3%worse
Long-stay residents whose ability to walk worsened9.9%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.5%25.6%18.9%better
Long-stay residents given the seasonal flu vaccine92.3%90.9%95.3%typical
Long-stay residents with pressure ulcers2.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control17.3%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%23.5%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine81.8%63.5%79.4%typical
Short-stay residents rehospitalized after admission30.1%26.0%22.6%worse
Short-stay residents with an outpatient ER visit5.3%13.7%12.0%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.

45.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.5%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
40.0%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 40.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.5%CMS range 38.6–54.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.2–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge26.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 2.8–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.55
RN hours/ resident / day
0.90
LPN hours/ resident / day
2.85
Aide hours/ resident / day
4.31
Total nurse hours/ resident / day
0.17
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 103 beds and averages 81.1 residents a day — about 79% occupied, or roughly 22 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.554 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above 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 3.70 hrs/resident/day on weekends vs 4.56 on weekdays — 19% thinner on weekends. RN hours go from 0.71 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

9
deficiencies at the latest standard inspection (2024-06-06)
8
at the previous standard inspection (2022-10-28)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2022-10-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, and facility policy review, the facility failed to immediately consult the physician for one (Resident #58) of three sampled residents reviewed for diabetic management, when the resident was admitted to the facility on high-dose insulin and other diabetic medications, but had no orders for blood glucose (blood sugar) monitoring. Additionally, the facility failed to consult with the physician when Resident #58's insulin was withheld due to hypoglycemic (low blood sugar) episodes. The failed practices resulted in Resident #58 requiring emergency care, administration of intravenous (IV) glucose, and subsequent hospitalization to correct a critically low blood sugar. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.10(g)(14) Notification 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2022-10-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure diabetes management was provided in accordance with accepted standards of nursing practice for one (Resident #58) of three sampled residents reviewed for diabetic management. Specifically, the facility failed to ensure when Resident #58 was admitted to the facility with orders for high-dose insulin and oral diabetes medications, that licensed nursing staff identified and addressed a lack of orders for blood glucose (blood sugar) testing and initiated monitoring for signs/symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Additionally, licensed nursing staff withheld Resident #58's physician-ordered insulin without discussing that decision with the resident's physician. The failure to regularly check blood glucose levels and monitor for signs/symptoms of hypoglycemia resulted in Resident #58 requiring emergency care for a critically low blood glucose level, administration of intravenous (IV) glucose, and hospitalization. It was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of video from the resident's room and record review, the facility failed to provide care in a dignified and respectful manner for one resident (Resident #4), in a review of eight sampled residents. The resident presented with ALS (amyotrophic lateral sclerosis, a progressive neurological disorder that leads to muscle weakness, atrophy, and eventually paralysis. ALS does not typically affect cognitive functions like thinking, memory, or sensory perception). The resident was dependent on staff for cares and had difficulty communicating both verbally and in writing. The resident wanted a drink and Certified Nurse Aide A interaction with the resident was impatient and dismissive when the resident attempted to communicate his/her preferences. The resident became upset causing further difficulty for the resident in his/her attempts to communicate. The resident felt the aide was disrespectful and should not work with vulnerable residents. The facility census was 85. On 6/4/25 the administrator was notified of the past non-compliance that occurred on 5/28/25.…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2024-11-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide care in a dignified and respectful manner for two dependent residents (Resident #4 and #5), in a review of six residents. Residents reported Certified Nurse Aide (CNA) C was rough while providing care. The facility census was 86. Review of the facility policy Right to Dignity, Respect and Freedom, revised 10/25/23, showed the following: -Residents will be treated with consideration, respect and dignity; -Residents have a right to self-determination. 1. Review of Resident #5's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/24, showed the following: -The resident had severely impaired cognition; -He/She was dependent on staff for toileting, hygiene, and transfers; -He/She was always incontinent of bladder and bowel. Review of the resident's Care Plan, dated 9/15/24, showed the following: -Be patient and positive with the resident; -The resident needed assistance with activities of daily living (ADLs); -Be calm and gentle, do not rush 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-17 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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 observations, interviews and record review, the facility failed to maintain the temperature at a safe and comfortable level for the residents who resided on the third floor, when the blower units for the air conditioner were no longer functioning. The facility did not monitor the air temperatures while waiting for the units to be replaced and did not move residents to an area of the facility that maintained acceptable temperatures. This affected rooms 321 through 331 on the third floor. The facility census was 80. Review of the facility policy for Extreme Temperatures dated [DATE] showed the following: -In the event of a power loss, this facility's central air conditioning and heating systems will not function as they are not on the generator. The follow guidelines should be followed to ensure resident safety during times of heat or air conditioning loss; -Air conditioning Loss: In the event that there is a loss of function in the cooling system during hot weather, the following procedures are to be…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-06 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to serve the proper size entree to residents on a regular diet and mechanical soft diets, and failed to served pureed food items according to the spreadsheet menu to all residents on a pureed diet. The facility census was 73. Review of the undated facility policy, Portion Control, showed the following: -Individuals will receive the appropriate portions of food as defined by the state regulations and as planned on the menu. Control at the point of service is necessary to assure that the appropriate portion is served; -Use standardized recipes to avoid waste caused by overproduction. Recipes should be adjusted as needed and the yield and serving size specified on each recipe. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so that the proper portion can be referenced for each special diet; -Serve the food with ladles, scoops, spoodles and spoons of standard sizes which match the menus. Scales should be used as needed to weigh meat portions. Scoops should be…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain the ice machine to be free of an accumulation of debris, failed to ensure food and beverage items were labeled, dated, properly stored and discarded when expired, failed to ensure open cans of foods were properly maintained during food preparation; failed to ensure a scoops was not stored inside a bulk food container, and failed to ensure staff used safe food handling techniques during meal service in the dining room. The facility census was 73. 1. Review of the undated facility policy, Cleaning Instructions: Ice Machine and Equipment, showed the ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. Observation on 6/3/24 at 12:20 P.M. and on 6/4/24 at 9:11 A.M. showed the ice machine in the main kitchen had a buildup of pink and black debris on the white plastic interior portion of the unit. A small amount of white crusty debris was in the corners near the hinges. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said an outside…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for four residents (Resident #3, #5, #2, and #1), in a review of six residents who had indwelling medical devices or open wounds. Staff failed to utilize Personal Protective Equipment (PPE) while providing high-contact care activities or wound care. The facility had six residents with indwelling urinary catheters (a sterile tube inserted into the bladder to drain the bladder of urine), one resident with a wound vac (wound management system for open draining wounds), and one resident with a tube feeding (a tube inserted into the stomach to provide nutrition, water and medications). The facility census was 89. Review of Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multidrug-Resistant Organisms (MDROs, organisms resistant to antibiotic treatment), dated 7/12/22, showed the following: -Summary of recent changes…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-06 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 updated pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) education as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines and failed to provide the option to receive the updated vaccination for four residents (Resident #318, #271, #54, and #275), who were admitted after new guidance was released, in a review of 18 sampled residents. The facility census was 73. Review of the facility policy Pneumococcal Policy dated 7/2016 showed: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccination 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-06 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, bed rails/ assist bars as part of a regular maintenance program to identify areas of possible entrapment for four residents, (Resident #1, #24, #32, and #271) in a review of 18 sampled residents who used bed rails. The facility census was 73. Review of the facility's Side Rail Assessment and Consent Policy, dated (last reviewed/revised) 11/16/2023, showed the following: -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The safety of the residents, staff, and visitors are a primary concern. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an injury of unknown origin as required to the state survey agency for one resident (Resident #51), in a review of 18 sampled residents. The facility census was 73. Review of the facility policy, Abuse Prevention, date (last revised 09/10/23), showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Identification: -Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The administrator and director of nurses (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident;…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to thoroughly investigate bruising of unknown origin that occurred for one resident (Resident #51), in a review of 18 sampled residents, to identify cause. The facility census was 73. Review of the facility policy, Abuse Prevention, date (last revised 09/10/23), showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The administrator and director of nurses (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident; -The…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-06-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 medication was administered per policy and as ordered, for one resident, Resident #55. The resident had a feeding tube (a tube inserted through the skin and the stomach wall to access for liquid nutrition and medications). Staff administered the resident's medications and did not flush appropriately between medications, and did not follow facility policy when preparing medications for dissolved medications or flushing with administration. This resulted in a medication error rate of 23.3% with 43 opportunities observed with ten errors. The facility census was 79. Review of the facility's General Guidelines for Administering Medications via Enteral Tube (Enteral feeding tubes allow liquid food to enter your stomach or intestine through a soft, flexible tube which enters a surgically created opening in the abdominal wall) Policy, revised January 2018, showed the following: -The facility assures the safe and effective 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-06 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain and repair essential food preparation equipment in the main facility kitchen. The facility census was 73. 1. Observation on 6/3/24 at 1:51 P.M., showed the meat slicer sat on a metal tray on top of the metal preparation counter and was covered with a vinyl/plastic cover. A layer of yellowish grease or liquid sat in the bottom of the tray and the base of the meat slicer sat in the liquid. During interview on 6/3/24 at 1:56 P.M. and on 6/4/24 at 2:24 P.M., the Dietary Director said the following: -She had worked at the facility for 16 years in dietary and had been the dietary director since September 2023; -The meat slicer was broken and had been broken for a couple of years. The grease in the bottom is from the meat slicer possibly leaking oil. The machine has not been in use. 2. During interview on 6/5/24 at 9:36 A.M., the Consultant Dietitian said the meat slicer had not worked since the COVID-19 pandemic and had not been used much in the last 2-3 years. During interview on 6/5/24 at 9:50 A.M. and at 1:00 P.M., 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to transfer one resident, (Resident #1), of 3 sampled residents, after the resident repeatedly requested to be transferred to bed due to pain. The facility census was 92. The facility did not provide a policy for review regarding response to resident call lights when requested. 1. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/27/23 showed: -The resident is able to make him/herself understood and able to understand others; -The resident is alert and oriented and able to make decisions; -Dependent upon staff all Activities of Daily Living (ADL's); -Dependent upon two staff members for transfer from bed to wheelchair and wheelchair to bed; -Diagnoses of and coronary artery disease (CAD-caused by plaque buildup in the wall of the arteries that supply blood to the heart) and peripheral vascular disease (PVD-a systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, document review, and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent potential food borne illness for residents who received meals from the kitchen. Specifically, the facility: - Failed to ensure leftover food items stored in the refrigerators and freezers were dated, labeled, and tightly sealed. - A scoop used in a bulk flour bin was properly stored. - Kitchen equipment, shelves, and floors were free from excessive dirt, grease, and/or debris. - Floor tiles and a handwashing sink were maintained in good repair. - Sanitizer concentration in the dish machine and three-compartment sink was regularly tested and documented. - Dietary staff washed their hands when contaminated, prior to handling food. - Sanitizer water buckets and mop buckets were kept/stored away from food preparation areas and stored food/beverages. - Stock was stored off the floor. The failed practices had the potential to affect all 66 residents who resided in the facility and received food from the kitchen.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-28 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 observations, interviews, product information review, and policy review, the facility failed to ensure all medications and biologicals were labeled in accordance with accepted professional principles and expired medications were removed from stock to prevent their inadvertent administration to residents who received medications from two of two medication carts. Specifically, observations revealed multi-dose medications were opened, but were not labeled with the opened date, and multi-dose medications that were dated were kept in the medication carts beyond the manufacturer's specified timeframes for use. Findings included: Review of a facility policy titled, Medication Storage and Maintenance, dated August 2018, revealed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers, or dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The policy also indicated, 3. Drug containers that have…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-28 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours of admission to address individualized care needs for one (Resident #58) of six newly admitted residents whose records were reviewed for baseline care plans. The failed practice had the potential to affect 13 residents who were newly admitted to the facility within the last 30 days. Findings included: A copy of the facility's policy on baseline care plans was requested from the Minimum Data Set (MDS) Coordinator on 10/26/2022 at 4:34 P.M., but was not received as of the end of the survey (10/28/2022). Review of an admission Record revealed the facility admitted Resident #58 on 09/27/2022 with diagnoses that included type 2 diabetes mellitus, depression, and a history of pulmonary embolism (blood clot in the lung). Review of an admission MDS, federally mandated assessment tool, dated 10/04/2022, revealed Resident #58 had a Brief Interview for Mental Status score of 15, which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 interviews, record review, and facility policy review, the facility failed to ensure the comprehensive care plan addressed diabetes management for one (Resident #58) of three sampled residents reviewed for insulin use. This had the potential to affect 11 residents who received insulin injections. Findings included: 1. On 10/26/2022 at 4:34 P.M., a copy of the facility's policy on care plans was requested from the MDS (Minimum Data Set) Coordinator and was not received by the end of the survey (10/28/22). Review of an admission Record revealed the facility admitted Resident #58 on 09/27/2022 with a diagnosis of type 2 diabetes mellitus. Review of an admission MDS, a federally mandated assessment tool, dated 10/04/2022, revealed Resident #58 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident received insulin injections daily. Review of an Order Summary Report revealed Resident #58 was admitted on [DATE] 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-28 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility document review, it was determined the facility failed to ensure one (Registered Nurse #1) of four licensed nursing staff reviewed received training and demonstrated competency with diabetes management. This affected one (Resident #58) of two residents receiving insulin under the care of RN #1. Findings included: On 10/28/2022 at 1:34 P.M., Registered Nurse (RN) #3, a member of the administrative nursing staff as a Minimum Data Set (MDS) Coordinator and Wound Care Nurse, stated the facility did not have a policy for staff training and competencies. During the survey conducted from 10/24/2022 through 10/28/2022, facility failures with diabetes management for Resident #58 were identified. The resident was admitted with a diagnosis of type 2 diabetes mellitus and orders for high-dose insulin, but no orders for blood glucose monitoring. Licensed nursing staff failed to identify and address the lack of blood glucose monitoring for Resident #58 and failed to consult the physician regarding the need to withhold the resident's insulin 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-28 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, document review, and facility policy review, the facility failed to ensure COVID-19 vaccination education and declinations were documented in the medical record for two (Resident #11 and Resident #58) of five sampled residents reviewed for immunization documentation. Findings included: Review of an undated facility policy titled, Resident COVID-19 Vaccination Policy, revealed, [Facility] will verbally offer the COVID-19 vaccine to all residents, including boosters. The policy also indicated, [Facility] will offer education to the residents on the COVID-19 vaccine and will educate the resident if they wish to be educated. If the resident refuses to discuss the COVID-19 vaccine and the COVID-19 pandemic, [Facility] staff will respect their wishes and the [sic] end conversation politely about COVID-19. Additionally, the policy indicated, [Facility] will provide the COVID-19 consent form to the resident and/or family if they choose to receive the vaccine. During an interview on 10/26/2022 at 12:46 PM, the Registered Nurse Infection Preventionist (RN…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-09-20 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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

    Based on observation, interview and record review, the facility failed to ensure staff served food items that were palatable, conserved nutritive value, flavor and appearance and failed to ensure the foods were served at a safe and appetizing temperature. The certified census was 70 and the licensed only census 23. 1. Review of the facility policy titled, Diet Order, dated January 2019, showed: -The facility staff is expected to follow the ordering physicians or Licensed Personnel's diet order as documented in the Electronic Medical Record (EMR). These orders are to include texture and liquid consistency; -Residents diet orders may be downgraded but not upgraded for resident convenience in eating; -It is the policy of this Home to ensure all residents receive a balanced diet; -Meals should be attractive, palatable and appetizing at an appropriate temperature; -Meals shall be served in a palatable and appetizing manner. Facility Dining Service staff shall make rounds to ensure satisfaction; -Temperatures shall be taken before serving of the food. The expectation of this facility is…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-09-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that nursing staff washed their hands after each direct resident contact and when indicated by professional practices during personal care, for one resident (Resident #8) in a review of 18 residents and for two additional residents (Resident #404 and #405). The facility census was 70. 1. Review of the facility policy Handwashing dated July 2016 showed the following: -The purpose was to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents and visitors; -All facility personnel must wash their hands for 15 seconds under the following conditions: 1. When coming on duty; 2. Between resident contacts; 3. After handling contaminated objects; 4. When hands were obviously soiled; 5. Before performing invasive procedure; 8. Before handling clean or soiled linens; 9. Before performing resident care procedures; 12. After contact with blood, body fluids, excretions, secretions, mucous…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$11,536 in federal fines across 4 penalties.

  • $2,797 — penalty dated 2023-11-13
  • $2,447 — penalty dated 2023-11-06
  • $2,098 — penalty dated 2023-10-30
  • $4,194 — penalty dated 2023-10-10

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

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$11.0M
Net patient revenuemost recent cost report
-5.6%
Operating marginrevenue minus expenses
$837K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 6%Other / private 51%

This home reported $837K paid to related parties (affiliated landlords or management companies) in its most recent 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

$366per resident / day
operating cost
$11,137per month
≈ monthly operating cost
$347per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265783. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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