Birch Pointe Health And Rehabilitation
3705 S Jefferson Ave, Springfield, MO 65807 · For profit - Limited Liability company · 120 certified beds · (417) 889-0773 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2021
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
- about 22% 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.5% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 5.3% | 5.4% | better |
| 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 | 0.0% | 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 | 10.3% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.6% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.8% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.4% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.0% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 30.7% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.6% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.2% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.64 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.52 | 2.33 | 1.80 | better |
* 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.
48.8% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.4% 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 57 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 48.8%CMS range 40.8–59.8 | 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 | 10.0%CMS range 7.3–13.6 | 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 | 68.4% | 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 | 57.9% | 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 | 52.6% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 88.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 7.2% | 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 | 6.3%CMS range 3.3–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 120 beds and averages 106.0 residents a day — about 88% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.82 hrs/resident/day on weekends vs 3.41 on weekdays — 17% thinner on weekends. RN hours go from 0.69 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care per standards of practice when facility staff failed to assess, monitor, care plan, and provide treatment for one resident (Resident #1) related to his/her surgical incision to his/her cervical (C) spine (back of neck) resulting in the incision dehiscing (surgical incision edges separated) and greenish-white drainage. The facility census was 111. Review of the facility policy/procedure titled, Wound Care, revised October 2010, showed the following: -The purpose of the procedure was to provide guidelines for the care of wounds to promote healing; -Staff to verify there is a physician's order for the procedure; -Staff to review the resident's care plan to assess for any special needs of the resident; -Staff to document all assessment data obtained when inspecting the wound (wound bed color, size, drainage, etc.); -Staff to document if the resident refused the treatment and the reason why; -Staff to notify the supervisor if the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-13 · 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 observations, interviews, and record review, the facility failed to ensure food items were stored in accordance with professional standards of practice for food service safety when expired foods were found in kitchen storage areas. Review of the facility's policy titled, Food Receiving and Storage, revised 10/2017, showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 1. Observation and interview on 02/10/25, at 9:01 A.M., alongside the Certified Director of Food Service (CDFS), showed a refrigerator in the main kitchen had an opened five-pound container of cottage cheese with a best by date of 02/01/25. The CDFS confirmed this food item was expired. Observation and interview on 02/12/25, at 9:02 A.M., alongside the CDFS, showed the dry storage room of the main kitchen had 15, 12-ounce cans of evaporated milk with best by dates of 05/02/24. The CDFS confirmed the items were expired. Observation and interview on 02/12/25, at 10:18…
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 before2025-02-13 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote each resident's right to self-determination of care when staff did not provide showers as preferred and care planned for six resident (Resident #6, #7, #10, #30, #39, and #66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting,…
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 before2025-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received their scheduled showers for six resident nts (Resident (R) R6, R7, R10, R30, R39, and R66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, showed the followng: -Residents who…
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 · E2025-02-13 · 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
Based on record review and interview, the facility failed administer psychotropic drugs only when medically necessary when staff failed to educate the residents and/or residents' representatives of the risks and benefits prior to starting the drugs, failed to monitor and document adequate behaviors indication to use the drugs, failed offer nonpharmacological interventions, and failed to monitor adverse side effects for antipsychotic, antidepressant, and anti-anxiety medication use for four residents (Resident #54, #60, #64, and #80) of five residents reviewed for unnecessary medication use. Review the facility's policy for Antipsychotic Medication Use, revised July 2022, showed the following: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; -For enduring psychiatric conditions,…
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 · E2025-02-13 · 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 observations, interviews, and record review, the facility failed ensure storage of medication per standards of practice and in a manner that prevented possible of expired medications/supplies when staff failed to remove expired medications/supplies from one of two medication storage rooms and two of four medication carts. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation on 02/13/25, at 9:07 A.M., with Licensed Practical Nurse (LPN) 4 of the medication cart at the nurses' station on Hall 400 showed one open box and one unopened box of Assure Prism blood glucose control solution with the expiration date of 12/07/24 were found in the first drawer…
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 before2025-02-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an effective infection control and prevention program was maintained for six residents (Resident #101, #211, #212, #215, #359, and #54) of 25 residents reviewed for infection control when the facility failed to clean and disinfect patient care equipment in between resident use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, showed the following: -Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Association (OSHA) Bloodborne Pathogens Standard. -Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment); -Reusable resident care equipment is decontaminated and/or sterilized between residents…
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 · D2025-02-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documented evidence the facility documented residents' and/or their representatives grievances and provided grievance decisions/resolutions after grievances were voiced for two residents (Resident #60 and #91) of 34 sampled residents. Review of the facility's policy titled, Grievances and Complaints Policy and Procedure, revised 12/2016, showed the following: -The facility had adopted an internal grievance procedure providing for prompt and equitable resolution of complaints/grievances of all types, including but not limited to, those alleging any discriminatory action prohibited by or in violation of patient rights, applicable state and/or federal law, internal policies, rules, enactments, guidelines, codes, regulations, or initiatives issued or enacted by any and all entities holding jurisdiction over this facility; -Depending on the nature of the complaint/grievance, there may or may not be an official form that should be completed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications when on one resident (Resident #54), of five residents reviewed for unnecessary medication use, receive opioid pain medication without assessment of the proper pain level, without documention of non-pharmalogical interventions attempted first, and without documented monitoring for side effects. Review of the facility's policy for Medication Therapy, revised April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; -Upon or shortly after admission, and periodically thereafter the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen to identify whether there is a clear indication for treating that individual with the medication; the dosage is appropriate; the frequency of administration and duration of use are appropriate; and potential or suspected side effects are present. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-12 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to take steps to prevent further abuse and protect resident safety when staff failed to implement and care plan consistent and effective interventions for one resident (Resident #1) after resident-to-resident altercations with five residents (Resident #2, #3, #4, #5, and #6) resulting in continued altercations. The facility census was 99. Review of the facility's policy titled, Reporting Abuse, undated, showed the following: -The facility will not condone resident abuse by anyone, including staff members and other residents; -Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of the facility's policy titled, Preventing Resident Abuse, undated, showed the following: -Preventing resident abuse is a primary concern for the facility. It is the facility's goal to achieve and maintain an abuse-free environment; -The facility's abuse prevention program includes, assessing, care planning, and monitoring residents with needs 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 before2023-12-01 · 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, the facility failed maintain an effective infection control program when staff failed to properly dispose of used Personal Protective Equipment (PPE - gloves, gowns and masks) and failed to don the appropriate PPE when entering isolation rooms with residents positive with Coronavirus Disease 2019 (COVID-19); when staff failed to implement source control when the facility had resident positive for COVID-19; and when staff failed to separate and appropriately handle hall trays and cleaning supplies removed from isolation rooms with residents positive with COVID-19. The facility census was 93. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, showed the following: -The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency;…
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 19 citations
- Potential for harm · E2023-12-01 · tag F0609 — failed to report abuse allegations — patternTimely 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, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving five residents (Resident #3, Resident #25, Resident #50, Resident #66, and Resident #82) out of 24 sampled residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Investigate and report any allegations of abuse within timeframe as required by federal requirements. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, 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 · Ecited before2023-12-01 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated when staff failed to document investigations of alleged abuse involving five residents (Resident #3, Resident #25, Resident #40, Resident #66 and Resident #82) out of a sample of 24 residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Administration will protect residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal…
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 before2023-12-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #42) and failed to consistently provide oral care assistance for one resident (Resident #91), with known dental issues, out of a sample of 24 residents. The facility had a census of 93. Review of the facility's policy titled, Activities of Daily Living (ADLs - dressing, grooming, bathing, eating, and toileting), Supporting, revised March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care,…
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 · D2023-12-01 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #94) who was transferred out to the hospital. A sample of three residents' closed records was selected for review in a facility with a census of 93. Review of the facility's policy titled Bed-Hold Charge, undated, showed the following: -In the absence of the resident from the facility, a daily bed-hold charge will be made until the personal effects of the resident are removed from the facility or a stop bed-hold agreement is signed; -Bed-hold provisions vary according to whether the resident is private or medicare, or medicaid for hospital/therapeutic leave so long as the facility occupancy rate is 97% or higher in accordance with state regulations, up to a maximum of 12 therapeutic leave days in a six month period; -If the resident's insurance covers the bed-hold period, the resident will not be billed separately for the amount covered. 1. Record review of Resident #94's face sheet…
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 · D2023-12-01 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 verify a resident's code status and failed to provide basic life support timely, including cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one resident (Resident #95) of a sample of two residents who was found unresponsive. The facility census was 93. Review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised 02/2018, showed the following: -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless the resident is a known that a Do Not Resuscitate (DNR - order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis)); -If the resident's DNR status is unclear, CPR will be initiated…
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 · D2023-12-01 · 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 communicate and collaborate, consistent with professional standards of practice, with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center for one resident (Resident #73), out of a sample of two residents, when staff did not consistently send and receive communication with the dialysis facility regarding each dialysis session. The facility census was 93. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised October 2010, showed the following: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of proactive, the comprehensive person-centered care plan, and the resident's goals and preferences; -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's 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 · Dcited before2023-08-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when the staff failed to document routine offers of bathing or showering and failed to address resident's preferences for shower/baths in the resident's care plan for one resident (Resident #1). The facility had a census of 94. Review of the facility's policy titled Bath, Shower/Tub, revised February 2018, showed the following: -The purpose of the procedure is to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident skin; -Staff should document the date and time the bath was performed; -Staff should document the name and title of the individual(s) who assisted the resident with the bath; -Staff should document how the resident tolerated the bath; -Staff should document if the resident refused the bath, and what interventions were taken by staff; -Staff should notify the supervisor if the resident refuses the bath; -Report other information in accordance with facility…
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 · D2023-08-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, observation, and record review, the facility failed to obtain timely catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care orders, failed to obtain an order and document an indwelling catheter change, and failed to obtain a timely urine specimen when a resident had symptoms of a urinary tract infection and contact the physician on the delay for one resident (Resident #1). The facility also failed to follow physician's orders when staff inserted a different sized catheter than ordered for two residents (Resident #1 and #2). The facility's census was 94. Review of the facility's catheter procedure, revised October 2010, showed the following: -Staff should verify there there is an order for the procedure; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Equipment necessary for the procedure included a catheter tray, size (of the catheter)…
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 · D2023-08-01 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to obtain a timely ultrasound and notify the physician when a stat (emergent) ultrasound imaging was delayed for one resident (Resident #1) who complained of abdominal tenderness. The facility's census was 94. Review of the facility's agreement for portable imaging services, dated 11/03/20, showed the following: -The imaging provider shall provide a qualified technologist who shall perform non-stat (routine) imaging exams as requested. Every effort will be made to complete routine exams the same day ordered. If the provider is unable to complete a routine exam the day it is ordered, the facility will be notified and the exam will be performed the next day; -The provider shall be available 24 hours a day, seven days a week, for stat requests. Stat services provided for critical situations requiring rapid results. The facility agrees that stat orders are provided for critical situations requiring rapid results. The facility should use its best efforts to limit stat orders to urgent situations where the absence of an order could…
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 before2021-06-02 · 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 staff failed to ensure staff performed hand hygiene when leaving rooms or the hall, failed to sanitize equipment used by multiple residents after possible contamination, and failed to ensure trash cans holding potentially hazardous gloves and gowns were properly covered on the Coronavirus Disease 2019 (COVID-19) (an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) quarantine hall. Additionally, the facility failed to develop a complete program for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella). The facility's census was 104. 1. Record review of the facility's Policies and Practices - Infection Control, revised October 2018, showed the objectives of the facility's infection control policies and practices are to: -Prevent, detect, investigate, and control infections in the facility; -Maintain 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 · E2021-06-02 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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 protect residents from misappropriation of property when staff discovered missing doses of controlled medications, that were in the possession of the facility, for three residents (Resident #2, #5, and #303). The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record must be made for each resident who will by receiving a controlled substance. Do not enter more…
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 before2021-06-02 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Record review of Resident #95's face sheet showed the following: -readmitted to the facility on [DATE]; -Diagnoses included fracture (broken) and displacement of the resident's left femur (thigh bone). Record review of the resident's Nursing Admission/readmission Assessment, dated 5/4/21, showed the following: -The resident had 2+ edema (swelling with moderate pitting, when pushed, indentation subsides rapidly) to his/her left lower leg; -Cognitively intact; -Substantial/maximal assistance needed for transfers and bed mobility; -Lower extremity range of motion impairment on one side; -Partial loss of voluntary movement in legs and feet. No side specified; -Non-weight bearing. No side specified. Record review of the resident's physician order, dated 5/4/21, showed the following: -No bearing weight on the resident's left leg; -May perform range of motion (ROM) as tolerated. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required moderate assistance 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 · E2021-06-02 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 all controlled drugs were reconciled periodically per standards of practice when staff failed to ensure outgoing and incoming nurses counted narcotics during shift change on two of three units in the facility. The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record must be made for each resident who will by receiving a controlled substance. Do not enter more than one prescription per page. This record must contain: name 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 · D2021-06-02 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to treat one resident (Resident #202) in a manner that promoted dignity and respect when staff did not verify the resident's Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) vaccination status prior to admitting the resident to the COVID-19 quarantine hall when the resident voiced he/she did not wish to be placed on the quarantine hall if avoidable. The facility's census was 104. According to the Center for Disease Control (CDC) regarding COVID-19, people are considered fully vaccinated two weeks after their second dose in a two-dose series, such as the Pfizer or Moderna vaccines, or two weeks after a single-dose vaccine, such as Johnson & Johnson's [NAME] vaccine. Record review of the CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, dated 4/27/21, showed the following: -Quarantine is no longer…
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 · D2021-06-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 obtain timely treatment orders for new pressure sores, failed to document completing the treatment as ordered once order was received, and failed to complete a timely full assessment of the pressure sores for one resident (Resident #87) who developed two newly identified pressure sores. The facility's census was 104. Record review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, revision dated July 2017, included the following: -Assess the resident on admission and repeat weekly and upon any changes in condition; -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Identify any signs of developing pressure injuries (i.e., nonblanchable (stays red when pushed indicating poor blood flow) reddening of the skin); -Inspect pressure points (i.e., sacrum (the triangular-shaped bone at the base of the spine), heels, buttocks, coccyx (tailbone), elbows etc.); -Wash skin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-06-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to obtain physician's orders related to the use of as needed use of oxygen, and failed to update a resident's care plan to reflect the use of as needed oxygen, for one resident (Resident #43). The facility census was 104. Record review of the facility's Oxygen Administration Policy, dated October 2010, showed the facility must verify a physician's order for this procedure, review the resident's care plan for any needs of the resident, and assemble the equipment and supplies as needed. 1. Record review of Resident #43's medical record showed the following: -admitted to the facility on [DATE]; -Diagnoses included of chronic rhinitis (sneezing or a congested, drippy nose) and heart failure (when heart muscle doesn't pump blood as well as it should). Record review of the resident's progress note dated 4/15/21, at 1:50 A.M., showed the physician ordered a chest xray and electrocardiogram (EKG - a test that measures the electrical activity 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 · D2021-06-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 27 opportunities, resulting in an error rate of 7.4 percent affecting one residents (Resident #54). The facility's census was 104. Record review of the facility's Documentation of Medication Administration policy, dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered, as well as reason(s) why a medication was withheld, not administered, or refused (as applicable). 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: -Diagnoses included heart failure (a chronic condition in which the heart does not pump blood as well as it should), irritable bowel syndrome without diarrhea (an intestinal disorder causing pain in the belly, gas, and constipation), and gastrointestinal…
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 · D2021-06-02 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each 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 observation, interview, and record review, the facility failed to accurately assess the resident's dental condition and determine if the resident wished to receive dental services for one resident (Resident #85). The facility census was 104. Record review of the facility's Dental Services Policy, revised December 2016, showed the following: -Routine and emergency dental services are available to meet the resident's oral health need as in accordance with the resident's assessment and plan of care; -Routine and 24-hour emergency dental services are provided to residents through a contract agreement with a licensed dentist that comes to the facility as needed, referral to the resident's personal dentist, referral to community dentist, or referral to other health care organizations that provide dental services; -A list of community dentists available to provide dental services to residents is available from social services; -Social services representatives will assist residents with appointments,…
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 · D2021-06-02 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility staff failed to ensure approved recipes were followed when preparing pureed foods to ensure residents received the correct consistency and correct amount of calories and nutrients. The facility census was 104. Record review of the facility's Pureed Diet Policy, no date, showed the following: -The purred diet is a modification in consistency of a regular or any therapeutic diet providing foods of smooth semi-liquid or semi-solid consistency requiring no mastication prior to swallowing; -Often individuals on pureed diet texture are nutritionally compromised; -Preparation of the pureed diet should maximize flavor appeal and nutrient density. 1. Observation on 5/58/21, at 10:38 A.M., showed the following: -There were two residents on pureed diets; -Dietary Aide (DA) T made chicken broth. He/she did not measure out the powdered broth. He/she poured some powdered chicken broth out in a measuring cup and added water. The amount of powder chicken broth in the measuring cup was unclear due to the powder being uneven in the cup;…
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 ANTHONY & BRYAN ADAMS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 3.0 | -1.0 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 37 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DVORAK, NORA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNF | since 01/01/2017 |
| LOWE, CLINTON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/15/2024 |
| SCROGGINS, JESSE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 08/28/2024 |
| ADAMS, ANTHONY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 05/13/2015 |
| ADAMS, BRYAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 05/13/2015 |
| ALUMNO, MARTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2024 |
| 3B HOLDINGS, LLC | Organization | ADP OF THE SNF | since 05/13/2015 |
| 50 EGGS, LLC | Organization | ADP OF THE SNF | since 01/01/2020 |
| FIRST SECURITY BANCORP | Organization | ADP OF THE SNF | since 05/13/2015 |
| FIRST SECURITY BANK | Organization | ADP OF THE SNF | since 05/13/2015 |
| INCITE REHAB, LLC | Organization | ADP OF THE SNF | since 12/28/2017 |
| LTC SYSTEMS/RX, LLC | Organization | ADP OF THE SNF | since 12/28/2017 |
| MILLER COMMERCE ASSETS, LLC | Organization | ADP OF THE SNF | since 05/13/2015 |
| PHARMACY CONSULTS, LLC | Organization | ADP OF THE SNF | since 12/28/2017 |
| PRIMROSE SENIOR LIVING, LLC | Organization | ADP OF THE SNF | since 05/13/2015 |
| RELIANCE HEALTH CARE, INC. | Organization | ADP OF THE SNF | since 12/28/2017 |
| ELLIS, JOHN | Individual | ADP OF THE SNF | since 12/28/2017 |
| KOEHLER, TOBEY | Individual | ADP OF THE SNF | since 12/28/2017 |
| MAINORD, WILLIAM | Individual | ADP OF THE SNF | since 12/28/2007 |
| MCGINNIS, LARRY | Individual | ADP OF THE SNF | since 12/28/2017 |
| MILLER, MATTHEW | Individual | ADP OF THE SNF | since 05/13/2015 |
| PEDIGO, RITA | Individual | ADP OF THE SNF | since 12/28/2007 |
CMS files one row per role, so the 30 rows in the source record cover these 22 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.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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.
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 265865. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-13, 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.