Living Community Of St Joseph
1202 Heartland Road, Saint Joseph, MO 64506 · Non profit - Corporation · 96 certified beds · (816) 671-8500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 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 | 20.1% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.0% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.0% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 7.4% | 2.3% | 2.0% | worse |
| 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 | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.9% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.4% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.5% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.0% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 36.4% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.1% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.21 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.81 | 2.33 | 1.80 | typical |
‡ 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.
64.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 422 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.8% 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 199 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 0.61 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.4%CMS range 58.9–68.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.7–13.8 | 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 | 63.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.9% | 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 | 80.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 94.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 5.5–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 96 beds and averages 88.5 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.71 on weekdays — 12% thinner on weekends. RN hours go from 0.83 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed ensure one of 6 sampled residents (Resident #1) received adequate assistance and supervision to prevent accidents when the facility staff transferred the resident to a standing position without a gait belt. The resident ambulated to the restroom, notified staff that he/she felt dizzy, the staff member left the resident alone to go obtain a gait belt and the reisdent fell. The resident fractured his/her left hip and required surgery. The facility census was 77. Review of the facility policy titled, Integrated Fall Management Policy, dated 8/24/17, showed: -Fall Risk assessments are to be completed quarterly and upon significant change of condition; -Identify other risk factors in the Minimum Data Set (MDS) to identify additional risk factors and interventions; -Residents at risk for falls have an individualized resident centered care plan developed based upon the fall risk assessment; -Include other professionals to assess or intervene regarding fall risk prevention; -Residents are provided education, regarding her/his fall…
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 before2026-04-09 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that medications used in the facility were labeled in accordance with professional standards, including expiration dates for seven sampled residents (Residents #10, #41, #46, #50, #79, #97, #102); when the facility had an open expired insulin pen (Resident #10); when the facility had an opened multi-use medicated nasal spray and eye drops with no open dates (Resident #79 & Resident #97); when the facility had an uncapped, pre-primed insulin needle and pen with dried blood on it (Resident #41); also when the facility had an opened large, floor stock powdered fiber medication with no open date, as well as two expired floor stock oral medications (Aspirin and guaifenesin); when the facility had four vials of expired blood sugar testing solutions that expire 90 days after opening and additionally when the facility had a clear storage bag containing medications for three different residents (Residents #102, #46, & #50). This affected seven of the 18 sampled residents. The facility census was 87.Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-09 · 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 and interview the facility failed to store food in accordance with professional standards for food service safety when the facility failed to ensure food items were dated with an open date or expiration date, and when the facility failed to dispose of food items that had been expired. This had to potential to affect all residents. The facility census was 87.Review of the facilities Food Storage- Perishable dated 2012, showed:-Sanitary procedures will be maintained in perishable food storage to keep foods safe, wholesome and appetizing, and to prevent contamination;-Refrigerated frozen products must be properly stored immediately upon delivery;-All prepared food stored in the refrigerator units should be in covered, seamless containers or otherwise suitably protected with used by date. Containers should be arranged so that free circulation of air was allowed at all times.-The policy did not address food labeling, dating of foods or expired foods. Observation of the walk in refrigerator on 04/06/2026 at 8:48 A.M. showed:-Open package of lettuce not sealed shut and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility staff did not utilize enhanced barrier precautions by wearing appropriate protective equipment when caring for residents with an indwelling device for three residents (Residents #10, #37 & #39) and additionally when the facility staff did not change gloves between dirty and clean tasks for one resident (Resident #39); this affected three of the 18 sampled residents. The facility census was 87.Review of the facility's undated Enhanced Barrier Precautions (EBP) Policy showed:-EBP expands the use of protective equipment and refers to the use of gowns and gloves during high-contact resident care activities;-EBP will be utilized for any resident that has an infection with a Multi-Drug Resistant Organism (MDRO)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-02 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 two of 25 sample residents (Resident (R) 54 and R23) reviewed for self-administration of medications were permitted to exercise their resident rights. Specifically, the facility failed to ensure medications were not left at the bedside of R54 who was not assessed to be able to self-administer medications safely; and the facility failed to ensure R23, who desired to self-administer medications and was assessed to be safe to do so was permitted to. The facility census was 80. Findings include: Review of the facility's Self-Administration of Medications policy, dated 08/31/23, revealed the purpose was, To enhance resident independence to self-administer medications. The policy indicated, . Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe . The nursing associates will assess each resident's mental and physical abilities to determine whether…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-02 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member for two of two residents (Resident (R) 26 and R32) reviewed for abuse out of a total sample of 25. This failure created the potential for abuse of other residents. The facility census was 80. Findings include: Review of the facility's Abuse Prevention Plan, dated 07/21/22, revealed, Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation must report immediately, without fear of reprisal and/or retaliation . Any allegations involving abuse, neglect, misappropriation of resident property and/or financial exploitation will be investigated . Measures will be taken to identify the source of the alleged abuse and prevent future incidents. Investigative packets will be utilized to systematically direct the team through the investigative process. Any evidence gathered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure two of 25 sampled residents (Residents (R)37 and R21) were provided with sufficient supervision and assistive devices to prevent accidents. R37 experienced a fall in which she fell forward out of the bed onto the floor on 09/20/24. There was a lack of interventions implemented in response to the fall and seven days later, R37 experienced another fall onto the floor. R37 sustained injuries including abrasions to her knees, a nosebleed, bleeding gums, bruise to her right cheek, and experienced hip and knee pain. R21 wandered through out the First-Floor [NAME] unit and into residents' rooms, including the rooms of R37 and R32, putting herself and other residents at risk of injuries. R21 wandered at night into residents' rooms when there was less staffing on the unit to supervise her and when she had the potential to startle residents who were sleeping. The facility census was 80. Findings include: Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 25 sampled residents (Resident (R) 21) residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the resident to have unmet care needs. The facility census was 80. Findings include: Review of R21's Face Sheet, found under the Profile tab in the electronic medical record (EMR), indicated an admission date of 09/07/18 with diagnoses of dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease. Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. Review of the facility's undated policy titled Comprehensive Assessments and Care Planning, provided 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.
- Potential for harm · D2025-01-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to have an end date for an as needed (PRN) psychotropic medication for two of six residents (Resident (R) 16 and R282) reviewed for unnecessary medications out of a total sample of 25. The failure had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness. The facility census was 80. Findings include: Review of the facility's Psychotropic Medication Use policy, reviewed on 09/07/23, revealed, . Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior . PRN orders for psychotropic drugs are limited to 14 days. If the medical provider believes that it is appropriate for the PRN order to be extended beyond 14 days, the medical provider should document their rationale in the resident's medical record and indicate the duration for the PRN order . 1. Review of R16's Resident Face Sheet, located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure the medical record was accurate and complete for one out of 25 sampled residents (Resident (R) 37). R37's record did not include the updated Preadmission Screening and Resident Review (PASRR) Level 1 form, and R37 was documented with a serious mental illness diagnosis of bipolar disease that was not accurate. This created the potential for R37 to experience the stigma associated with mental illness and for staff and medical providers not to have full and accurate information about R37's mental health condition. The facility census was 80. Review of the facility's admission Prescreening for Individuals with Mental Retardation or Mental Illness policy, dated 2021, revealed, Missouri law mandates preadmission screening for all individuals with mental illness (MI) or mental retardation (MR) who apply to long term care facility . The policy indicated if the resident had a serious mental illness diagnosis, a referral would be made 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 · E2023-03-06 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents (Residents #994, #995, #996, #997, #998, and #999). The facility census was 95. Review of facility policy, Refunds - Credit Balances, dated [DATE], showed: -Purpose: To prevent fraud, waste, and abuse and manage reimbursement; -Policy: All credit balances will be reviewed within 30 days from being identified. Under the Patient Protection and Affordable Care Act, Title VI entitled Transparency and Program Integrity section 6402; overpayments from Federal payers must be refunded within 60 days after the date on which the overpayment was identified. Federal payers include Medicare A and B, Medicaid, Veterans Association, Medicare Advantage or any other payer under title XVIII and XIX; -Private Pay - For residents who have discharged and have a credit balance, complete…
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 15 citations
- Potential for harm · E2023-03-06 · 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 four of ten sampled staff (Cook A, Housekeeper A, Physical Therapy Assistant, Culinary Services Aide F). The facility census was 95. Review of the facility policy, Abuse Prevention Plan, dated 7/21/22, showed: -All potential employees will be screened during the hiring and re-hiring process for a history of abuse, neglect, financial exploitation, misappropriation of resident property, or mistreatment of a vulnerable adult; -Inquiries will be made into the state licensing authorities or Nursing Assistant Registry; -The facility will prohibit employment of individuals with a disciplinary action in effect against their professional license by a state licensure body as a result of a guilty finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. 1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 they completed and submitted to Centers for Medicare and Medicaid (CMS) comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected two of 19 sampled residents (Residents #28 and #84). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. - Within seven days after a facility completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. A facility must be capable 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 · E2023-03-06 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 they completed, submitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) on a quarterly basis. This affected six of 19 sampled residents (Residents #28, #68, #75 #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every 3 months. - Within seven days after a faciltiy completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 they completed and transmitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected six of 19 sampled residents (Residents #28, #68, #75, #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change int he resident's physical or mental condition. c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · 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, record review and interviews, the facility failed to assure staff used the residents' comprehensive assessments to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for four of 19 sampled residents (Resident #55, #89, #120 and #382). The facility census was 95. Review of the facility provided Comprehensive Care Plan Workload document, dated 9/1/22, showed: - The Minimum Data Set (MDS: a mandated assessment tool completed by the facility) Coordinator will use the Baseline Care Plan to build a Comprehensive Care Plan. Review of the Comprehensive Assessments and Care Planning policy, dated 2017, showed: - Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan to address residents who have had a significant change in health care status and dependent upon staff to carry out their activities of daily living for one sampled resident (Resident #95) out of 19 sampled residents. The facility census was 95. Review of the facility's undated policy for care plans showed: - Its purpose is to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs using the resident assessment instrument (a tool to help care providers develop individualized care plans based on assessments of residents' strengths, limitations, and preferences) (RAI) specified by the State. - The assessment must accurately reflect the resident's status. - A facility must conduct a comprehensive assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · 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 observation, interview and record review, record review, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice for two of 19 sampled residents (Resident #41 and #78) when staff failed to label and date a dermal patch for Resident #41 and failed to clarify a physician's order for scheduled nasal spray for Resident #78. The facility census was 95. Review of the facility's undated Physician Service Policy, showed: - All physician's orders will be followed as prescribed; - If physician's orders are not followed the reason shall be recorded in the resident's medical record. Review of the facility's Transdermal Drug Delivery System (patch) Policy, revised, August, 2014 showed: - Remove the old patch; - Label patch with date and nurses initials; - Apply new patch firmly to skin. 1. Review of Resident #41's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/14/22, showed: -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good personal hygiene for two of 19 sampled residents (Resident #39 and #95) who required assistance to perform activities of daily living. The facility census was 95. Review of the undated facility policy for activities of daily living showed: - The purpose is to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). - Residents unable to carry out ADLs independently will receive the services necessary to maintain grooming and personal hygiene. - Care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistant with hygiene (bathing and grooming). - If resident refuses care, associates will approach at a different time, or having another associate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 date and time enteral feeding bag (bags that are used with feeding pumps) to ensure residents receiving nutrition via feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) are not receiving spoiled formula, for one resident (Resident #382) out of nineteen sampled residents. The facility census was 95. Review of the undated facility policy for Monitoring Residents Receiving Enteral Feedings (a form of nutrition that is delivered into the digestive system as a liquid) showed: - The nutritional status of resident's who receive enteral nutrition/feedings will be evaluated and monitored on an ongoing basis by the Dietitian/designee to assure their nutritional needs are being met. - Procedure: A resident who obtains nutrition per an enteral feeding will receive appropriate treatment and services to prevent complications and 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 · E2023-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 provided proper respiratory care for four of 19 sampled residents (Residents #1, #78, #95 and #120) when staff failed to properly clean oxygen concentrator filters and when staff failed to follow orders for oxygen therapy. The facility census was 95. Review of the facility's undated physician service policy showed: - All physicians' orders will be followed as prescribed; - If physicians' orders are not followed the reason shall be recorded in the resident's medical record. Review of the facility's oxygen therapy policy, dated 6/12/04, showed: - Oxygen therapy is initiated per a physician's order; - A specific order for liter flow must be ordered by the physician; - Adjust the liter flow according to physician's order; - Document the oxygen setting in the medical record. Review of the facility's cleaning of oxygen equipment policy, dated June 2017, showed: - It is the policy of the facility to adhere to standards of practice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-06 · 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
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 six medication errors out of 25 opportunities for error, resulting in a medication error rate of 32%. This affected three residents sampled for medication administration (Residents #1, #41, and #78). The facility census was 95. Review of the facility's Medication Administration Procedures Policy, dated December 2017, showed: - Oral Medication Administration: o Wash hands when beginning a medication pass; o Avoid touching the tablet or capsule unless wearing gloves. - Eye Drop Administration: o With gloved finger, gently pull down lower eyelid to form a pouch while instructing the resident to look up; o Instruct resident to close eye; o When eye is closed, use one finger to compress the tear duct in the inner corner of the eye for 1 to 2 minutes. - Nasal Spray Administration: o Instruct resident to hold head in an upright position, slightly tilted forward; o Use finger of the other hand to close the nostril…
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 before2023-03-06 · 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 observations, interviews, and record review, the facility failed to store drugs and biologicals in a locked storage area to ensure drugs and biologicals were inaccessible to residents when medications were found in four residents' (Residents #1, #5, #15, and #78) rooms with no physicians' orders and failed to discard expired medications when expired medications were found in the rooms of three residents (Residents #1, #15 and #78). The facility census was 95. Review of the facility's policy, storage of medication in the facility, dated August 2014, showed: - It is the policy of the facility to ensure proper and safe storage of medications; - Outdated and contaminated medications are to be immediately removed from inventories; -No expired medication will be administered to residents. 1. Review of Resident #1's physician's order sheet (POS), dated 2/2/23 through 3/2/23, showed: - Start date: 1/10/22 - Alpha [NAME] skin oil (used to treat dry skin), use after bathing on Tuesdays and Fridays; - No order 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 · E2023-03-06 · 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 food was not served at an appetizing temperature to eight of nineteen sampled residents (Resident #30, #73, #88, #89, #91, #229, #232, and #284). The facility had a census of 95. Review of the facility policy, Maintaining Proper Food Temperature during Food Service, dated 2012, included the following: -Food will be maintained at proper hot and cold temperatures prior to and during meal service to assure food quality and tastiness/palatability as well as food safety; -Temperature of hot food will be 135 degrees or higher during tray assembly; -Temperatures of cold food foods will be 41 degrees Fahrenheit or less during tray assembly; -Temperatures will be taken and recorded for all hot and cold items at all meals. Temperatures will be recorded; -Heating food in the steam table was prohibited. Heating food 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 · E2023-03-06 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 serve meals according to scheduled meal times. This affected five of nineteen sampled residents (Resident #2, #12, #30, #88, and #232) This had potential to impact all residents residing in the community. The facility census was 95. The facility did not provide a policy on meal times. 1. Review of the signs posted in the main dining rooms on each floor showed: -West hallway kitchenettes; -Breakfast 7:30 A.M. -Lunch 12:00 P.M. -Dinner 5:30 P.M. -South hallway kitchenettes; -Breakfast 8:15 A.M. -Lunch 12:45 P.M. -Dinner at 6:15 P.M. 2. Observation of lunch service on the second floor on 2/27/23 showed: -Cold food loaded onto food carts 11:39 A.M.; -Hot food loaded onto food carts at 12:07 P.M.; -Food carts leaving kitchen to provide meal service 12:16 P.M.; -The lunch cart arrived to the west kitchenette at 12:20 P.M.; -The first tray was served at 12:30 P.M., thirty minutes after posted start time; -The last tray was served at 1:04 P.M.,…
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 before2023-03-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance to professional standards of food service safety when staff failed to fully date opened items, utilize proper hand washing, and failed to ensure all areas of the kitchen and food storage areas remained clean (dry food storage, walk through cooler, food prep counter, and food transport carts). The facility census was 95. 1. Review of the facility policy, Food Storage-Perishable, dated 2017, included: -All storage that takes place in refrigerated and freezer areas will be maintained in a clean, sanitary condition; -All food items must be stored on shelving or drainage racks that allow the entire floor to be completely cleaned; -To facilitate floor cleaning, the lower shelf in walk-in coolers and freezers should be a minimum of six inches above the floor; -Refrigerators and freezers should be kept clean. Spills should be wiped up immediately; -All prepared food stored in the refrigerator units…
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 BENEDICTINE HEALTH SYSTEM — 23 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 | 4 of 5 | 2.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 22 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BYROM, AMY | Individual | CONTRACTED MANAGING EMPLOYEE | since 02/07/2022 |
| CARLEY, GERALD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/03/2018 |
| PRZYBILLA, STEVEN | Individual | CORPORATE DIRECTOR | since 07/01/2018 |
| BERGIEN, TRICIA | Individual | CORPORATE OFFICER | since 01/01/2017 |
| RYMANOWSKI, KEVIN | Individual | CORPORATE OFFICER | since 02/12/2014 |
| BENEDICTINE HEALTH SYSTEM | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/16/2001 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $863K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
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 265784. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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 →
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