Rest Haven Health Care Center
1800 South Ingram, Sedalia, MO 65301 · For profit - Corporation · 86 certified beds · (660) 827-0845 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $39,230 in federal fines (most recent 2026-05-12)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (68%) 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
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 | 33.1% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 70.6% | 18.5% | 6.5% | worse 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 | 1.8% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.7% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.3% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.2% | 90.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 17.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.9% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 5.0% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.9% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 19.1% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.95 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.18 | 2.33 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Met the expected recovery: 31.8% 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 22 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 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 31.8% | 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 | 22.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 31.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 86 beds and averages 60.6 residents a day — about 70% occupied, or roughly 25 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 1.72 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 1.33 hrs/resident/day on weekends vs 1.87 on weekdays — 29% thinner on weekends — a notable drop. RN hours go from 0.27 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 1 administrator has left in the past year.
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 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.
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.
37 citations, most serious first. The 12 most serious are shown; the remaining 25 are one tap away and print in full.
- Immediate jeopardy · J2026-01-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse, when staff found Certified Nurse Assistant (CNA) A in the resident's bed with his/her pants around his/her ankles, resident's pants and underwear off. CNA A admitted he/she sexually assaulted the resident. The facility census was 62.The administrator was notified on 01/06/26 of a past non-compliance immediate jeopardy (IJ) which occurred on 01/04/26. The administrator immediately began an investigation and began in-servicing all staff on abuse and neglect who were on duty and continued in-servicing staff not on duty prior to their shifts. The IJ was corrected on 01/04/26. 1. Review of facility's abuse and neglect policy, revised 06/2024, showed the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, facility staff failed to ensure one resident (Resident #1) remained free from accidents, when Licensed Practical Nurse (LPN) A heated water in a microwave and gave it to the resident, the resident spilled the hot water on him/herself, which resulted in a burn injury to the resident's legs. Facility staff failed to prevent one resident (Resident #2) from falling, when staff assisted the resident with one staff member and rolled the resident to his/her side during care and the resident fell from his/her bed. The facility's census was 53.The administrator was notified on 05/12/26 of past Non-Compliance which occurred on 05/08/26. On 4/17/26, the nursing staff were in-serviced on the facility's Fall Prevention and Safe Resident Handling policies, and on 05/07/26 to 05/08/26, staff were in-serviced on abuse and neglect, how to heat foods/liquids for residents and safe temperatures to serve hot liquids to residents. 1. Review of the facility's policies showed 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 · Dcited before2026-05-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, facility staff failed to maintain professional standards of care, when Licensed Practical Nurse (LPN) A administered treatment to one resident's (Resident #1's) burn injury, without obtaining an order from the physician. The facility's census was 53.The administrator was notified on 05/12/26 of past Non-Compliance which occurred on 05/08/26. On 05/07/26, staff were in-serviced on when to notify management of incidents, and to always obtain an order from the physician for treatments, and on 05/08/26, LPN A was in-serviced and counseled on when to obtain orders from the physician for a treatment. 1. Review of the facility's Transcription of Orders/Following Physician's Orders policy, dated 05/18/24, showed the purpose is to ensure that all physician's orders are followed. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 03/17/26, showed staff assessed the resident as cognitively intact, and without impairments to hands/arms or legs. Review of the resident's progress note, dated 05/07/26 at 5:49…
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 · F2026-01-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to ensure the dish washing machine operated according to manufacturer's instructions to adequately prevent cross contamination of kitchen wares. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. The census was 64.1. Review of the facility's Resident Food: Storage and Sharing policy, revised 09/16/2024, showed the purpose of the policy is to ensure resident food storage is safe with sanitary storage, handling and consumption. Review showed food items will be dated after opening and prepared food that is dated three days after it is placed in the refrigerator will be discarded.Review of the kitchen policies provided by the facility showed they did not contain a kitchen specific food labeling and storage policy. Observation on 12/30/25 at 12:00 P.M., showed the dry goods storage area contained a service cart with six plastic containers 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 · Fcited before2025-03-06 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen and nebulizer tubing in a manner to prevent the spread of bacteria for three residents (Resident #1, #18, and #35) out of three sampled residents. Facility staff failed to maintain proper infection control practices for three residents (Resident # 13, #18 and #25) out of four sampled residents catheters.Facility staff failed to perform appropriate hand hygiene, and glove changes during wound care for one resident (Resident #2) out of two sampled residents. Staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for four (Resident #1, #2,#25, #40) of six sampled residents. Facility staff failed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-06 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 52. 1. Review of the facility's Infection Preventionist Policy, revised 03/05/2025, showed the facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. 2. During an interview on 03/05/25 at 2:43 P.M., the Chief Nursing Director said they do not currently have an infection preventionist (IP). He/She said the Assistant Director of Nursing (ADON) is working on getting certified. During an interview on 03/06/25 at 7:10 A.M., the Director of Nursing (DON) said they do not currently have an IP. He/She said he/she is not sure who is monitoring, tracking, educating facility staff members on infection control. He/She just recently became the DON. He/She said he/she usually works the floor as the charge nurse. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide a comfortable, safe, and homelike environment for residents, when staff failed to maintain walls, floors, bathrooms, and the building structure of resident occupied rooms and common areas. The facility census was 52. 1. Review of the facility's Safe and Homelike Environment policy, dated 06/0524 showed: - In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk; - The facility will create and maintain, to the extent possible, a homelike environment that demphasizes the institutional character of the setting; - Housekeeping and maintenance services will provide as necessary to maintain a sanitary 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 · E2025-03-06 · 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, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for eight residents (Resident #1, #2, #9, #12, #18, #25, #45 and #258) out of 12 sampled residents. The facility's census was 52. 1. Review of the Facility's Comprehensive Care Plans policy, dated 10/31/24, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan or each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Resident specific interventions that reflect the reisdent's needs and preferences. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff used to assess the care needs of the resident, dated 1/31/25,…
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.
- Potential for harm · Ecited before2025-03-06 · 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, facility staff failed to provide services to meet professional standards when staff failed to document and obtain orders for hospice services on two (Resident #18 and #45) of three residents who receive hospice services, to obtain orders for an indwelling catheter for three(Resident #12, #13, and #18) out of three sampled residents, failed to document weekly skin assessments for three (Resident #9, #12, and #13) of six sampled residents and failed to document a smoking assessment on one (Resident #9) of five residents who smoked. The facility census was 52. 1. Review of the Coordination of Hospice Services policy, dated 05/18/24, showed the policy did not contain direction to obtain a physician order for hospice. Review of the facility's Indwelling and Suprapubic Catheter Use and Removal policy, dated 06/26/24, showed: -If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-06 · 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, facility staff failed to provide care to meet basic hygiene needs for five sampled residents (Resident #11, #12, #13, #27, and #42,). The facility census was 52. 1. Review of the facility's Activities of Daily Living (ADL) policy, dated 05/18/24, showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable; -Care and services will be provided for the following ADL's, toileting, bathing, dressing, grooming and oral care. Review of the facility's Resident Showers policy, dated 06/26/24, showed: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per standards of practice; -Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety; -Partial…
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 before2025-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to lock medication carts when unattended and failed to safely store hazardous materials in a manner to prevent accidents in two of three shower rooms. The facility census was 52. 1. Review of the facility's Medication Storage policy, dated 05/18/24, showed: -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 2. Observation on 03/03/25 at 11:28 A.M., showed the medication cart at the nurse station unlocked and unattended. Observation showed residents in the hall near the nurses station. Observation on 03/05/25 at 8:36 A.M., showed the Director of Nursing (DON) left the medication cart unlocked and unattended at the nurses' station. Observation on 03/05/25 11:50 A.M., showed the medication cart at the nurse station unlocked 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 · E2025-03-06 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 services by sufficient numbers of nurse aides to provide nursing care to eight of 14 sampled residents (Resident #11, #12, #13, #25, #27, #31, #33, and #42) to ensure care and comfort of residents daily needs. The facility census was 52. 1. Review of the resident council meeting notes for December 2024, January 2025, and February 2025, showed the residents expressed concern for lack of staff, staff not answering call lights at night, staff not making the beds, night shift working with only one nurse for the entire building, not receiving ice water every shift and not enough aides to work on the 100 hall. Review of the facility's nurse staff punch detail dated 02/17/25 through 03/05/25 showed: -One licensed nurse and one certified nurse aide (CNA) on duty from 10:49 P.M. to 5:43 A.M. on 02/23/25 with a census of 57 residents; -One licensed nurse and one CNA on duty from 09:33 P.M. to 11:46 P.M., on 02/24/25 with a census of 57…
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 25 citations
- Potential for harm · E2025-03-06 · 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, facility staff failed to maintain a medication error rate of less than 5% out of 52 opportunities observed, 28 errors occurred, resulting in a 53.85% error rate, which affected three residents (Resident #4, #12, and #258) out of seven sampled residents. The facility census was 52. 1. Review of the Facility's Medication Administration policy, revised 06/26/24, showed: -General medication administration process: -Ensured that the six rights of medication administration are followed: -Right time; -Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time; -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. 2. Review of Resident #4 Physician's Order Sheet (POS), dated 03/05/25, showed: -Cetirizine (Antihistamine) 10 milligram (mg) tablet at 6:00 A.M.; -Fluphenazine (Antipsychotic) 5 mg tablet at 6:00 A.M.; -Jardiance (Treatment of type 2 diabetes mellitus) 25 mg tablet at 6:00…
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 · E2025-03-06 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, facility staff did not conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility census was 52. 1. Review of the facility's Facility Assessment Policy and Tool, dated 06/29/2023, showed: -The facility must update the Facility Assessment monthly and as necessary whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment; -The assessment must include the facility resident population, including but not limited to, both the number of and the facilities resident capacity, the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present in the population, the staff competencies that are necessary to provide the level and types of care needed for the resident population, the physicial environment, equipment, services, and other…
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 · D2025-03-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to provide thorough orders, monitoring, and ongoing communication with the dialysis (a treatment that cleans the blood when the kidneys fail to function properly) clinic for one of one resident (Resident #48). The facility census was 52. 1. Review of the facility's Dialysis policy, dated 03/18/22, showed the following: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing assessment and oversight of the resident before and after dialysis treatments; -Ongoing communication and collaboration with the dialysis clinic, regarding dialysis care and services; a. Coordination of physician services between the nursing facility and dialysis facility. For a resident receiving dialysis, the nursing home staff must immediately contact and communicate with the attending physician/practitioner, resident/resident representative, and designated dialysis staff regarding any significant changes in the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to ensure four out of six nurse aides ((NA) NA C, NA D, NA E, NA F) completed the nurse aide training program within four months of their employment in the facility. The facility census was 52. 1. Review of the facility's Nurse Aide Training policy, dated 05/18/24, showed the policy did not contain NA completion timeline or how to proceed if NA goes beyond the 120 day requirement. Review of the facility's Active Employee list showed: -NA C hired 04/03/24; -NA D hired 07/26/24; -NA E hired 08/30/24; -NA F hired 09/12/24; During an interview on 03/04/25 at 10:00 A.M., NA D said he/she has been working on the floor as an aide for eight months and has not been able to pass the testing required to become certified. He/She has to wait for certified staff or nurses to assist residents with care needs. During an interview on 03/06/25 at 7:10 A.M., the Director of Nursing (DON) said NA's are required to be certified within 120 days of hire. He/She is aware some of the NA's are beyond the required 120 days because they did not pass…
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 · F2024-04-25 · tag F0657 — failed to keep the care plan current — widespreadDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to review and revise care plans after falls for four residents (#4, #24, #36 and #47) of twelve sampled residents. Staff failed to invite residents to their care conference for two residents (#32 and #35) of twelve sampled of residents. The facility census was 45. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised 10/2016, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; -The care plan intervention is derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions; -If a significant change 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 · F2024-04-25 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated October 2023, showed the facility did not have an RN in the building for the dates of: -Sunday 10/01/23; -Saturday 10/14/23; -Sunday 10/15/23; -Saturday 10/28/23; -Sunday 10/29/23. 3. Review of the facility's RN staff schedule, dated November 2023, showed the facility did not have an RN in the building for the dates of: -Saturday 11/04/23; -Sunday 11/05/23; -Saturday 11/25/23; -Sunday 11/26/23. 4. Review of the facility's RN staff schedule, dated December 2023, showed the facility did not have an RN in the building for the dates of: -Saturday 12/09/23; -Sunday 12/10/23; -Saturday 12/23/23; -Sunday 12/24/23. 5. Review of the facility's RN staff schedule, dated January 2024 showed the facility did not have an RN in the building for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-25 · tag F0842 — failed to keep accurate, complete medical records — widespreadSafeguard 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
Based on observation, interview and record review, facility staff failed to keep residents medical record accessible and systematically organized in accordance with accepted professional standards for 23 residents (Resident #1, #4, #7, # 9, #13, #14, #17, #21, #23, #24, #26, #28, #31, #32, #35, #36, #37, #40, #41, #44, #47, #48, and #351) out of 23 sampled residents. The facility census was 45. 1. Review of sampled Resident #1, #4, #7, #9, #13, #14, #17, #21, #23, #24, #26, #28, #31, #32, #35, #36, #37, #40,# 41, #44, #47, #48, and #351 medical records showed the medical records for the following areas not accessible for: -Falls; -Skin assessments; -Wound documentation; -Labs; -Gradual Dose Reductions (GDR); -Pharmacy Recommendations; -Immunization Records. During an interview on 04/25/24 at 1:27 P.M., the Director of Nursing (DON) said his/her expectation with falls is they be documented and to include what happened, how it happened, assessments done, interventions and who was contacted. The DON said the facility does not currently have a system in place for this process. The DON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-25 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, facility staff failed to notify one resident's (Resident #26) representative in a timely manner after a report of potential abuse for one resident (Resident #1) out of twelve sampled residents. The facility census was 45. 1. Review of the facility's policy titled, Abuse Reporting and Investigation, undated, showed if a suspected and/or witnessed account of abuse is reported, such as physical, emotional, sexual, or major injury of unknown origin any of these must be reported to the Administrator, as well as the Director of Nursing (DON), the residents representative, doctor, and the State Agency as immediately but no longer than two hours after suspected incident. 2. Review of Resident #26's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/07/24, showed staff assessed the resident as: -Severe cognitive impairment; -Diagnosis of high blood pressure, Alzheimer's (a progressive disease that destroys memory and other important mental functions), anxiety, and depression. Review of the facility's Incident/Accident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-25 · tag F0641 — patternEnsure each resident receives an accurate 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 record review and interview, facility staff failed to document an accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff coded three (Resident #7, #23, and #40) of three sampled residents took an anticoagulant medication (medication used to thin the blood) when the residents were not prescribed an anticoagulant medication. The facility census was 45. 1. Review of the facility's MDS completion and submission timeframes policy, dated 2010, did not contain direction for coding the MDS assessment. Review of the Resident Assessment Instrument (RAI) manual, dated October 2023, showed: Do not code antiplatelet medications such as aspirin/extended release or clopidogrel (antiplatelet) as an anticoagulant. 2. Review of Resident #7's Quarterly MDS, dated [DATE], showed the MDS coded for use of an anticoagulant in the 7-day lookback period. Review of the resident's physician order sheet (POS), dated January 1 through January 31, 2024, showed the POS did not contain a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-25 · 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, facility staff failed to ensure multi-dose medications contained an open date and/or resident name, dispose of expired medications, and failed to store only medications in the medication storage refridgerator. The facility census was 45. 1. Review of the facility's Storage of Medication policy, revised 04/2007, showed facility staff were directed as follows: -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received; -Drug containers which have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to provide one resident (Resident # 32) out of one sampled resident with an appropriate follow-up plan/resolution in response to his/her grievances within 72 hours. The facility census was 45. 1. Review of the facility's policy titled, Resident Concerns and Grievances Policy and Procedures, undated, showed staff were directed to: -Responsed to resident/family shall be made as soon as possible and preferably immediately. Actions taken to resolve the complaint shall be made within 72 hours from the time the Concern/Grievance From was received; -Responsed may be written or verbal, depending on the situation. A Resident/family concern/grievance form is available; -Section three of the form is to be completed by the employee designated to ensure satisfaction with the resolution of complaints; -The Administrator or designee will then complete Section four of the form by checking the appropriate box indicating resolution or further actions required. All concerns/grievances forms will be signed off by the Administrator; -Responses,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews and record review, facility staff failed to report an allegation of physical and verbal abuse to the Department of Health and Senior Services (DHSS) for one resident (Resident #26) within the two hour timeframe. The facility census was 45. 1. Review of the facility's policy, Abuse Reporting and Investigation, undated, showed staff if a suspected and/or witnessed account of abuse is reported, such as physical, emotional, sexual, or major injury of unknown origin any of these must be reported to the administrator, as well as the Director of Nursing (DON), the residents representative, doctor, and the State Agency immediately but no longer than two hours after suspected incident. 2. Review of Resident #26's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/07/24, showed staff assessed the resident with severe cognitive impairment. Review of the facility's investigation, dated 04/13/24, showed the facility documented a suspected physical and verbal incident between the resident and Certified Nurse Aide (CNA) M. The report did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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, facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes when facility staff failed to provide the correct portion sizes to three residents (Residents #4, #31, and #44) of three residents sampled who received pureed food items. The census was 45. 1. Review of the facility's policies, showed the policies did not contain instructions for staff to prepare multiple portions of pureed food items. Review of the standardized menu for Week Four, Day Three showed residents receiving pureed food items were to receive one # 10 (3.2 ounces) scoop of beef stroganoff, one #8 (four ounces) scoop of egg noodles, one #10 scoop of green beans, one #10 scoop of sweet dinner roll, one #16 (two ounces) scoop of gooey butter bar and a beverage. Observation on 04/23/24 at 11:45 A.M., showed [NAME] L added two (4 oz) scoops of egg noodles, three (3 oz) scoops of beef stroganoff and beef broth to a food processor and pureed the items. The pureed items were placed in a pan and added to the serving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene and glove changes during incontinence care for one (Resident #14) out of one sampled resident. Facility staff failed to perform appropriate hand hygiene and glove changes during catheter care for two (Resident #4 and #36) out of two sampled residents. Facility staff failed to perform appropriate hand hygiene and glove changes during wound care for one (Resident #44) out of two sampled residents. The facility census was 45. 1. Review of the facility's policy titled, Standard Precautions, undated, showed staff are directed to: -Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; -Wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; -Wear gloves when touching blood, bodily fluids, secretions, excretions, 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 · Fcited before2022-12-09 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 39. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-09 · 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 staff failed to complete the required Minimum Date Sets (MDS), a federally mandated resident assessment, within the required timeframe for four sampled residents (Resident #9, #16, #26 and #39). Facility census was 39. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission; -Annual (Comprehensive) MDS completion date no later than assessment reference date (ARD) + 14 calendar days; -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type. 2. Review of Resident #9's medical record showed the resident admitted to the facility on [DATE]. Review of the resident's MDS record dated 4/21/22 to 9/15/22 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 · Ecited before2022-12-09 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for three sampled residents (Resident #2, #9, and #32). The facility census was 39. 1. Review of the facility's Bath, Showers/Tub Policy, revised February 2018, showed the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; Documentation: -Date and time shower/bath was performed; -Name and title of the individual who assisted the resident with the shower/tub bath; -Assessment data during the shower/tub bath; -How the resident tolerated; -If the resident refused the shower/tub bath, the reason(s). Reporting: -Notify the supervisor if the resident refuses the shower/tub bath. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/5/22, showed staff assessed the resident as follows: -Total dependent on staff for transfers, toileting, personal hygiene 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 · E2022-12-09 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to complete the side rail/bed rail risk of entrapment assessment, complete initial and/or annual entrapment assessments, and/or obtain consent for the use of side rails for five sampled residents (Residents #2, #15 #21 #25, #26). The facility census was 39. 1. Review of the Facility's Bed Rails Policy, revised 12/16, showed staff are directed as follows: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restrains unless necessary to treat a resident's medical symptoms. General Guidelines: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using bed rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-09 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications required for two residents (Resident #11 and #22) and failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for four sampled residents (Resident #14, #16, #21, and #25). The facility census was 39. 1. Review of the facility's Drug Reduction policy, undated, showed the following: -Resident who use antipsychotics drugs must receive a gradual drug reduction, unless clinically contraindicated in an effort to discontinue the use of such drugs; -When a drug reduction program has been implemented, such information shall be entered on the resident's plan of care to ensure that such reduction is closely monitored by the staff; -Clinically contraindicated means that a resident need not undergo a gradual dose reduction or behavioral interventions if the resident's physician provides a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-09 · 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 staff failed to store controlled medications (medications which fall under United States Drug Enforcement Agency (DEA) Schedules II-V, have a potential for abuse, and may lead to physical or psychological dependence) in a separately locked, permanently affixed compartment and failed to discard expired medications. The facility census was 39. 1. Review of the facility's Storage of Medication policy, undated, showed all controlled substances are stored under double-lock and key. Observation on 12/7/22 at 11:18 A.M., showed the locked medication storage room contained the following medication in an unlocked refrigerator: - One 30 milliliter (ml) bottle of Lorazepam (a controlled medication) 2 milligram (mg)/ml concentrate in a plastic see through box closed with a numbered, unbroken, plastic tamper seal; The box was not permanently affixed in the unlocked refrigerator. -Two one ml vials of Lorazepam injectable 2 mg/ml in a plastic see through box closed with a numbered, unbroken, plastic tamper seal. The box was not…
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.
- No harm found · C2025-03-06 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 52. 1. Review of the facility's Antibiotic Stewardship Program policy, revised 06/29/23, showed to optimize antibiotic use in our home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach: -The Antibiotic Stewardship Program (ASP) will comply with state and federal laws and regulations; -The ASP will be run by the facility Antibiotic Steward, who will lead the Antibiotic Stewardship Team (AST). At a minimum, the AST will be comprised of the Director of Nursing (DON), a nurse with administrative duties, and a charge nurse; -The facility ASP will use a systematic evaluation of ongoing treatment, -The facility will track and monitor antibiotic prescribing practices and resistance patterns among its residents; -The facility Antibiotic Steward will review and generate the Infection Log in the Point Click Care (PCC); -At 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.
- No harm found · C2024-04-25 · tag F0639 — widespreadMaintain 15 months of resident assessments in the resident's active clinical record.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility staff failed to maintain fifteen (15) months of Minimum Data Set (MDS), a federally mandated resident assessment tool, assessments in the resident's active record for eight (Resident #1, #7, #13, #17, #23, #24, #26, and #32) of eight of sampled residents who were admitted greater than 15 months. The census was 54. 1. Review of the facility's MDS completion and submission timeframes policy dated 2010, showed the policy did not contain direction for maintaining MDS assessments. Review of the Resident Assessment Instrument (RAI) manual, dated October 2023, showed that a nursing home must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. 2. Review of #1's medical record showed: -The resident admitted to the facility on [DATE]; -The record did not contain 15 months of MDS assessments. 3. Review of #7's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-04-25 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to complete or post required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 45. 1. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, showed within two hours of the beginning of each shift, the number of Licensed Nurses (Registered nurses, Licensed practical nurses, and Licensed vocational nurses) and the number of unlicensed nursing personnel (certified nurse aides) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Observation on 4/22/25 3:32 P.M., showed facility staff did not display the nurse staff posting sheet in an area readily accessible to residents and visitors. Observation on 4/23/25 9:32 A.M., showed facility staff did not display the nurse staff posting sheet in an area readily accessible to residents and visitors. Observation on 4/24/25 1:55 P.M., showed facility staff did not display…
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.
- No harm found · C2022-12-09 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to provided in writing the transfer/discharge notice to the resident and/or the resident's representative for four sampled residents (Resident #4, #11 #16, and #25). The facility census was 39. 1. Review of the facility's Transfer or Discharge Notice policy, dated 12/2016, showed facility staff are directed as follows: -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: -The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -An immediate transfer or discharge is required by the resident's urgent medical needs; -The resident and/or representative (sponsor) will be notified in writing of the following information: -The reason for the transfer or discharge; -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged ; -The facility bed-hold policy. 2. Review 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.
- No harm found · Ccited before2022-12-09 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 39. Review of the Center for Disease Control (CDC)'s Preparing for COVID-19 in Nursing Homes policy, updated on 11/20/20, showed facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities, because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of health care providers (HCP), and auditing adherence to recommended IPC practices. During an interview on 12/6/22 at 2:30 P.M., Licensed Practical Nurse (LPN) B said he/she is not certified yet. He/She said he/she is not enrolled in the Infection Preventionist (IP) CDC training. LPN B said this job duty was passed on to him/her…
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
$39,230 in federal fines across 2 penalties.
- $14,380 — penalty dated 2026-05-12
- $24,850 — penalty dated 2026-01-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RELIANT CARE MANAGEMENT — 34 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 | 1 of 5 | 1.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 1.6 | +0.4 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 2.4 | -1.4 vs chain |
The other 33 homes this chain runs (chain average 1.2★, 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 |
|---|---|---|---|
| DESTEFANE, RICHARD | Individual | CORPORATE OFFICER | since 06/01/2024 |
| RELIANT CARE MANAGEMENT COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2024 |
| ARSHAD, ABDULLAH | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2024 |
| FOSTER, GEORGANN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2024 |
| RELIANT CARE GROUP LLC | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | since 06/01/2024 |
| RICHARD J. DESTEFANE REVOCABLE LIVING TRUST | Organization | TRUSTEE OF THE SNF | since 06/01/2024 |
| BRUNSWICK PARK ASSOCIATES INC | Organization | ADP OF THE SNF | since 11/14/2024 |
| RCG INC | Organization | ADP OF THE SNF | since 11/14/2024 |
| RELIANT CARE GROUP OF WEBSTER INC | Organization | ADP OF THE SNF | since 11/14/2024 |
| REST HAVEN ASSOCIATES I LLC | Organization | ADP OF THE SNF | since 11/14/2024 |
| TLG II LLP | Organization | ADP OF THE SNF | since 06/01/2024 |
CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $54K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265854. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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.