Clearview Nursing Center
430 Salcedo Road, Sikeston, MO 63801 · For profit - Corporation · 90 certified beds · (573) 471-2565 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- about 28% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 | 12.8% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 18.5% | 6.5% | check this* — see note marked star 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 | 1.6% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.9% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.5% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.9% | 17.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.7% | 23.5% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 13.5% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.5% | 63.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 33.6% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.1% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.63 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 2.33 | 1.80 | typical |
* 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.
48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.6%CMS range 34.4–68.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.8–16.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.1% | 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 | 5.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 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 | 1.07 | 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 90 beds and averages 60.6 residents a day — about 67% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.03 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.50 hrs/resident/day on weekends vs 4.21 on weekdays — 17% thinner on weekends. RN hours go from 0.36 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Fcited before2026-03-05 · 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
Based on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures and practices for wound care for two residents (Residents #1 and #55) out of two sampled residents, one resident (Resident #4) for catheter (a flexible tube placed in the bladder to drain urine) care out of one sampled resident, and one resident (Resident #6) with a gastrostomy tube (g-tube - a medical device surgically placed through the abdomen directly into the stomach to deliver nutrition, fluids, and medication when oral intake is unsafe or insufficient) out of one sampled resident. The facility also failed to ensure laundry was processed in a way to limit the spread of infections. This practice could potentially affect all residents. The facility census was 62. Review of the facility's policy titled, Enhanced Barrier Precautions, revised March 2024, showed:- To prevent broader transmission of multi-drug resistance organisms (MDROs) and to help protect patients with chronic wounds and indwelling devices, enhanced barrier precautions (EBP) should…
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 · D2026-03-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff maintained or enhanced the quality of life for two residents (Residents #8 and #54) and failed to maintain the dignity of one resident (Resident #55) when left exposed during care out of 16 sampled residents. The facility's census was 62. The facility did not provide a dignity policy. 1. Observation on 03/02/26 at 12:11 P.M., of Resident #8 showed:- The resident sat in the hall and asked two different staff that passed by for a cup of coffee; - No staff acknowledged the resident. Observation on 03/02/26 at 12:31 P.M., showed:- The resident asked Certified Nursing Assistant (CNA) J if he/she could have a cup of coffee as CNA J walked by;- CNA J responded in a loud and stern voice, No, the kitchen is closed. CNA J continued to walk past the resident without offering another option or redirecting the resident. During an interview on 03/02/26 at 12:32 P.M., CNA J said the staff try not to give the resident coffee because it caused the resident to be anxious and then the resident wanted to get out 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 · D2026-03-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. Review of the facility's policy titled, Minimum Data Sets (MDS - a federally mandated assessment completed by the facility) and Care Planning Guidelines, dated September 2013, showed:- It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata (error) documents, and applicable federal guidelines as the authoritative guide for completion of MDS, care area assessments (CAA), and resident care planning. 1.Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture…
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 · D2026-03-05 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess for the risk of entrapment, review the possible risks and benefits of the side rails prior to installation or use, and the facility failed to obtain informed consent of the side rails prior to use for four residents (Residents #1, #6, #52, and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail assessment policy. 1.Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- Cognition moderately impaired;- No documentation of a side rail assessment or informed consent for the use of side rails. Observation on 03/02/26 at 1:10 P.M., 03/03/26 at 10:00 A.M., 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M., showed:- The resident's bed with both half side rails in an upright position. Observation on 03/04/26 at…
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 · D2026-03-05 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four out of four days. The facility census was 62.The facility did not provide a policy on nurse staff posting. Observations on 03/02/26 at 12:05 P.M., 03/03/26 at 9:00 A.M., 03/04/26 at 8:45 A.M., and 03/05/26 at 12:30 P.M., showed:- Daily nurse staffing posted on the east end of the facility near the nurses' station;- No daily nurse staffing posted at the main entrance of the facility or at the west end area of the facility;- Daily nurse staffing not posted in a prominent place readily accessible to all residents and visitors. During an interview on 03/05/26 at 1:30 P.M., Certified Nurse Aide (CNA) K said the nursing staff information had always been posted on the east end of the facility. He/she had never known of the staffing posted anywhere else in the facility. During an interview on 03/05/26 at 1:33 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument required to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for four residents (Residents #1, #6, #52 and #55) out of four sampled residents. The facility census was 62. The facility did not provide a side rail inspection policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of fracture (broken bone) of the left leg, pain, muscle weakness, and chronic obstruction pulmonary disease (COPD - a long-term chronic airway disease);- No maintenance inspection for the side rail. Observations on 03/02/26 at 1:10 P.M., and 03/03/26 at 10:00 A.M., of the resident's bed showed:- A side rail in the upright position on both half sides of the resident's bed and moved with minimal effort. Observation on 03/04/26 at 8:50 A.M., and 03/05/26 at 9:00 A.M, showed:- The resident lay in bed with both half side rails in an upright position. 2. Review of Resident #6's medical record…
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 · D2026-03-05 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure call lights were placed within reach to meet resident needs for five residents (Residents #5, #6, #52, #54 and #67) out of 16 sampled residents and one resident (Resident #12) outside the sample. The facility census was 62.The facility did not provide a call light policy. 1. Observations on 03/02/26 at 9:56 A.M., and 2:13 P.M., 03/03/26 at 8:33 A.M., and 12:47 P.M., and 03/04/26 at 2:28 P.M., of Resident #67 showed:- The resident lay in bed and the call light out lay on the floor out of the resident's reach;- The resident sat in a Geri-chair (a specialized, heavy padded recliner) and the call light lay on the floor out of the resident's reach. 2. Observations on 03/02/26 at 9:59 A.M., and 2:17 P.M., and 03/03/26 at 8:25 A.M., and 2:31 P.M., of Resident #52 showed:- The resident lay in bed and the call light lay on the floor out of the resident's reach. 3. Observations on 03/02/26 at 1:26 P.M., and 3:45 P.M., 03/03/26 at 8:25 A.M., 10:08 A.M., and 1:17 P.M., and 03/04/26 at 12:44 P.M., of Resident #5 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 before2026-03-05 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions), Abuse (infliction of physical, sexual or emotional injury/harm), and Neglect (failure to provide necessary services for an adult's safety or health) prevention for two Certified Nurse Aides (CNA) (CNA C and CNA D) out of two sampled CNAs. The facility census was 62.The facility did not provide a nurse aide in-service education policy. Review of the facility's 2026 Quality Assurance and Performance Improvement (QAPI) Plan showed:- The facility will provide the necessary training to enable staff to perform their jobs effectively;- Ongoing training includes mandatory all-staff competency updates addressing topics such as changes in policies and procedures and regulatory requirements. Review of the Facility Assessment, revised 01/21/26, showed:- Topics to be trained at hire and annually thereafter…
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 · D2024-12-06 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to respond or act upon grievances, and failed to keep documentation of inventory for two residents (Residents #23 and #48) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, Grievance Protocol, undated, showed: - The purpose of the grievance/complaint report and grievance log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; - The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation; - Grievance complaint should be filled out for resident articles that are lost or cannot be located; - Social Services and Administrator evaluate the monthly grievance log for trends or patterns and devise an action plan to correct issues. A new log should be completed each month. The facility did not provide an inventory policy. Review of the facility's Grievance Log showed an empty binder with no documentation of any reported…
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 · D2024-12-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a physician's order for code status for two residents (Residents #14 and #38) and consistently document a resident's code status with Full Code (cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR - does not want CPR) for one resident (Resident #35) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, DNR Protocol, not dated, showed: - The Social Services Designee (SSD) will be responsible to print all DNR order forms on lavender paper to be placed in the admission packet; - Once the DNR form is signed by the resident or legal representative it is to be signed by the physician; - The SSD will then complete the following: a green paper with Full Code or a red paper with DNR will be placed in the very front of the medical record in a plastic sheet protector; on the Physician Order…
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 16 citations
- Potential for harm · D2024-12-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. The facility did not provide a homelike environment policy. 1. Observations on 12/03/24 at 2:42 P.M., and 12/04/24 at 9:20 A.M., of the 100 Hall showed: - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Several areas of wallpaper peeled with exposed sheetrock located behind the bed near the window in room [ROOM NUMBER]; - A seat cushion cover worn with several peeled areas on a chair next to the bed near the door in room [ROOM NUMBER]; - Dark scuff marks and a three inch (in.) area of exposed sheetrock and peeled paint on the wall next to the door in room [ROOM NUMBER]. 2. Observations on 12/05/24 at 10:37 A.M., of the 300 Hall showed: - A loose and cracked piece of molding on the right side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0641 — isolatedEnsure 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 interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for two residents (Residents #4 and #51) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, MDS and Care Planning Guidelines, revised 10/01/15, showed: - It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI - a tool used to assist facility staff to gather defined information on a resident's strengths and needs) Manual, any published interim RAI manual errata (error) documents, and applicable federal guidelines as the authorative guide for completion of MDS, care area assessments (CAAs) and resident care planning; - The policy did not address the accuracy of MDS assessments. 1. Review of Resident #4's annual MDS, dated [DATE], showed: - The resident did not receive an anticoagulant (medication to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder, to determine the level of care needed) for two residents (Residents #4 and #43) out of two sampled residents. The facility census was 59. The facility did not provide a policy for a PASARR. 1. Review of Resident #4's medical record showed: - An admission date of 03/16/21; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and post traumatic stress disorder (PTSD - psychological distress following a traumatic event); - No documentation of the required level one PASARR screening upon admission to the facility. 2. Review of Resident #43's medical record showed; - An admission date of 01/08/20; - Diagnoses of bipolar (a mental disorder that causes unusual shifts in mood) and schizophrenia (a long term mental disorder that affects a person'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 · D2024-12-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement, monitor, and modify interventions to maintain acceptable parameters of nutritional status for one resident(Resident #14) out of two sampled residents. The facility census was 59. Review of the facility's policy titled, Weight Champion Program, not dated, showed: - Each community should designate a weight champion to assist in the oversight and monitoring of residents that have or are at risk for weight loss; - The purpose of this program is to take a proactive stance against weight loss and collaborate to decrease weight loss numbers; - The weight champion will be responsible for keeping the weight variance report from Matrix, as well being custodian of the daily, weekly and monthly facility weight lists; - The champion will review for completion during the next stand up meeting. The champion will request and monitor re-weights of residents; - Weights should be reviewed weekly in our Interdisciplinary Team (IDT) meeting; - Weights should be assessed by the IDT at the time that the loss is noted. If…
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 · D2024-12-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 37 opportunities with three errors made, resulting in an error rate of 8.11% for three residents (Residents #20, #34 and #38) out of eleven sampled residents. The facility's census was 59. Review of the facility's policy titled, Specific Medication Administration Procedures, dated July 2021, showed: - Prime insulin pen prior to use; - Dial up two units; - Hold pen upright and push the button on the end of the pen so a small drop of insulin appears; - Dial insulin to the desired insulin dose to be administered to the resident. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for one resident (Resident #6) out of one sampled resident. The facility failed to use proper hand hygiene during blood sugar testing for four residents (Residents #3, #10, #20 and #38) out of four sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility census was 59. Review of the facility's policy, titled, Enhanced Barrier Precautions to Infection Control Guidelines, updated 2024, showed: -To prevent broader transmissions of multi-drug resistance organisms (MDROs) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; - Examples of MDROs include, but are not limited to, methicillin-resistant staphylococcus aureas (MRSA), vancomycin-resistant enterococci (VRE), extended spectrum beta-lactamase (ESBL-producing enterobacterais) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-06 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two certified nurse assistants (CNA) (CNA A and CNA B) of two nurse aides sampled. The facility census was 59. The facility did not provide a nurse aide in-service policy. Review of the facility assessment, revised 02/06/24, showed: - Required in-service training for nurse's aides: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse preventions training; 3. Address areas of weakness as determined by the facility assessment and address the special needs of residents to as determined by the facility staff; 4. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. 1. Review of the facility's August 2023 - July 2024…
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 · F2023-10-20 · 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 failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP) (a professional who assures healthcare workers and residents are doing everything possible to prevent infection) position. This had the potential to affect all residents in the facility. The facility census was 52. Review of the facility's policy titled, Infection Prevent and Control Program, dated 02/07/23 showed the IP is qualified to conduct infection prevention and control activities as a result of education, training and experience (he/she will complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module). The facility did not provide documentation for any staff members that had completed the specialized training for the IP position. During an interview at 10/19/23 at 9:20 A.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) Coordinator said he/she and the Director of Nursing (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 · Dcited before2023-10-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation of a Level I Preadmission Screening and Resident Review (PASARR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for two residents (Residents #38 and #41) out of four sampled residents. The facility's census was 52. The facility did not provide a policy regarding PASARR. 1. Review of Resident #38's medical record showed: - An admission date of 03/08/21; - Diagnoses of major depressive disorder severe with psychotic symptoms (a serious medical illness that negatively affects how you feel, the way you think and how you act), generalized anxiety disorder (persistent worry and fear about everyday situations), and post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for six residents (Residents #13, #14, #18, #21, #31, and #38) out of 13 sampled residents. The facility census was 52. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed: - An individualized comprehensive care plan includes measurable goals and time frames that meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff); - A well-developed care plan will be oriented to managing risk factors, applying current standards of practice in the care planning process, assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; - The comprehensive care plan is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · 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 interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #18 and #31) out of two sampled residents. The facility census was 52. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed: - Care of the arteriovenous (AV) shunt/fistula/graft (a surgical connection between an artery and a vein): Keep the area clean and dry; Feel for the thrill (vibration caused by blood flowing through fistula, can be felt by placing finger above the fistula incision site) sensation daily; Inspect the access for redness, swelling, or warmth; Avoid constrictive clothing or jewelry that may bind the access site; No blood pressure taking or intravenous (IV) administration should be done in the arm of the access site; Avoid excessive pressure on the puncture site after dialysis; Watch for bleeding after dialysis; and Monitor for signs of infection. - Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 identify, assess and provide supportive interventions for two residents (Resident #21 and #38) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 52. The facility did not provide a PTSD policy. 1. Review of Resident #21's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, anxiety disorder (persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), and traumatic brain injury (TBI) (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 · D2023-10-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's gradual dose recommendations (GDR) for two residents (Resident #9, and #49) out of five sampled residents. The facility's census was 52. Review of the facility's policy titled, Drug Review, not dated, showed: - Antipsychotic (a medication used to treat psychosis or the loss of connection to reality) drugs should only be given when necessary to treat a specific condition; - Determine the most acceptable time frame to attempt reduction of the drug dosage from behavior evaluation; - Notify the physician of the findings and recommendations, obtain an order for attempts at reduction; - Instruct the resident; - Document the reductions and behavior pattern exhibited; - Report progress or lack of progress to the physician. 1. Review of Resident #9's medical record showed: - admission date of 01/18/23; - Diagnoses of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent worry and fear about everyday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 52. The facility did not provide a policy. Review of the facility's current employee list, dated 10/09/23, showed a hire date of 06/20/22 for the Dietary Manager (DM). During an interview on 10/17/23 at 8:58 A.M., the DM said he/she had been the DM since June 2022 and was not certified yet. Some certification classes had been taken, but he/she had not passed the certification test yet. During an interview on 10/17/23 at 9:25 A.M., the Administrator said the DM was not certified but had taken some of the training classes. The DM had been here since June 2022. The DM should have been certified already and had made an attempt to take the certification test but was unable to become certified yet.
- Potential for harm · Dcited before2023-10-20 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the required annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions), and 12 hours of training for two Certified Nurse Aides (CNA) (CNA C and CNA D) out of two sampled CNAs, which had the potential to affect all residents. The facility's census was 52. The facility did not provide a policy in regards to the required annual competencies for CNAs. 1. Review of CNA C's in-service record showed: - A hire date of 08/13/22; - No documentation of the annual Dementia Care training provided for August 2022 through August 2023; - No documentation of 12 hours of training provided for August 2022 through August 2023. 2. Review of CNA D's in-service record showed: - A hire date of 04/25/22; - No documentation of the annual Dementia Care training provided for April 2022 through April 2023; - No documentation of 12 hours of training provided for April 2022 through April 2023. During an interview on 10/18/23 at 3:27 P.M., the Quality Assurance nurse said the Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's family after a fall with an injury in a timely manner for one resident (Resident #1) out of three sampled residents at risk for falls. The facility census was 54. Review of the facility's policy titled, Charting and Documentation, dated March 2015 showed the staff to document the date and the time the family was notified and by whom. Review of the facility's policy titled, General Guidelines for Emergency Care, not dated, showed to follow the facility's guidelines to notify the resident's representative. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated, 07/20/2023, showed: - admission to the facility on [DATE]; - Diagnoses of hypertension, cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis that affects only one side of the body), and seizure disorder (a sudden alteration of behavior due to a temporary change in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to JAMES & JUDY LINCOLN — 56 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 55 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 55; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LINCOLN, JAMES | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/1999 |
| LINCOLN, JUDY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/1999 |
| MCMULLIN, SANDRA | Individual | W-2 MANAGING EMPLOYEE | — | since 09/24/2014 |
| CRANE, GARY | Individual | CORPORATE DIRECTOR | — | since 01/01/1999 |
| DRAKE, TIMOTHY | Individual | CORPORATE OFFICER | — | since 01/01/1999 |
| STUTTS, CHARLOTTE | Individual | CORPORATE OFFICER | — | since 01/01/1999 |
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 80% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 265614. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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 →
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