Neighborhoods At Quail Creek, The
1514 West Lark, Springfield, MO 65810 · For profit - Limited Liability company · 120 certified beds · (417) 889-1275 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
- a high payroll-based staffing rating (4/5)
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Apr 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — 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)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 | 3 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.9% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 13.5% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.4% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 4.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 22.7% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.9% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.6% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.4% | 17.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.1% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.1% | 26.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.1% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 2.11 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 2.33 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.0% 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 322 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.7% 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 136 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.0%CMS range 44.4–55.3 | 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 | 11.5%CMS range 9.0–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 39.7% | 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 | 50.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 28.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 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 | 1.5% | 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 | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.5%CMS range 5.8–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 92.6 residents a day — about 77% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.69 hrs/resident/day on weekends vs 4.35 on weekdays — 15% thinner on weekends. RN hours go from 0.70 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · E2026-06-26 · tag F0919 — failed to provide a working call system — patternMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to have a process in place to notify staff of call light notifications when call light pagers where not functioning, when the nursing station notification terminal was not receiving notifications, and when the system would reset a call light without it being answered by staff for four residents (Resident #16, #107, #115, and #62). The census was 96.Review of the facility policy titled, Call Lights: Accessibility and Timely Response, undated, showed the following:-This policy is to assure the facility is adequately equipped with a call light at each resident's bed;-Call lights will relay directly to staff or a centralized location to ensure appropriate response;-Staff will be educated on the proper use of the call system including how the system works;-Staff will ensure the call light is within reach of the resident;-Staff will report problems with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to keep all food safe from potential contamination at all times when staff failed to where hairnets properly while in working in the facilities kitchens. The facility census was 99. Review of the facility's policy titled Dietary Employee Personal Hygiene, dated 01/01/24, showed the following information: -The purpose was to prevent contamination of food by food service employees; -All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food; -Head coverings must be clean. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. -A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-16 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a sanitary environment for all residents and staff when staff failed to ensure ceiling vents, light covers, walls, and non-contact food surfaces were clean. The facility census was 99. Review of the facility's policy titled Standard Operating Procedure, Cleanliness and Sanitation of the Dining Room, dated 01/01/24, showed staff to routinely clean all areas of the dining room, including equipment such as service refrigerators, etc. Review of the facility's policy titled Equipment Cleaning and Sanitizing, dated 01/01/24, showed the following: -Equipment is washed, rinsed and sanitized after each use to ensure the safety of food served to residents; -Employees who use equipment will be responsible for washing and sanitizing after each use; -The food service manager will conduct a visual inspection of all equipment to be certain that it is being cleaned properly. 1. Observation on 08/12/24, at 8:52 A.M., ice machine in the main kitchen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the hot water temperatures at sinks at a temperature to prevent that reduced the possibility of burns when hot water in multiple resident access areas measured in access of 120 degrees Fahrenheit (F). The facility had a census of 99. Review of the the US Consumer Product Safety Commission (CPSC) document Avoiding Tap Water Scalds, dated 03/2012, showed the following: -The majority of injuries involving tap water scalds are to the elderly and children under the age of five; -The CPSC urges all users to lower their water heaters to 120 degrees F; -Most adults will suffer third-degree burns if exposed to 150 degreed F water for two seconds; -Burns will also occur with a six-second exposure to 140 degreed F water or with a thirty second exposure to 130 degree F water; If the temperature is 120 degrees F, a five minute exposure could result in third-degree burns Review of a facility policy entitled Safe Water Temperatures, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and effective medication administration system for all residents when staff failed to maintain an accurate reconciliation and accounting for controlled medications (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) for one resident (Resident #356) and when staff failed to destroy expired or unused medications for [NAME] and Chestnut Neighborhoods. The facility census was 99. 1. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -Any discrepancies which cannot be resolved must be reported immediately. Staff to notify the Director of Nursing (DON), charge nurse, or designee and the pharmacy and complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with standards of practice when staff failed to store controlled substances under two locks, when medication carts were left unlocked when unattended, when staff left medications on the nightstand of one resident (Resident #70), and when staff removed prescription labels from medications. The facility census was 99. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -It is the policy of the facility to ensure all medications housed on the premises are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security; -All drugs and biologicals will be stored in locked compartments (such as medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature…
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 before2024-08-16 · 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 implement an effective program of infection control when staff failed to communicate an infection control plan to all staff and implement a consistent infection control plan for one resident (Resident #17) who had a current diagnosis of Clostridium difficile (C. Diff - a highly contagious germ that causes diarrhea and inflammation of the colon). Facility staff also failed to perform hand hygiene per standards of practice when providing cares to two residents (Resident #17 and Resident #67) and when administering medication per a feeding tube for one resident (Resident #2). Facility staff also failed to use infection control practices per standards of practice when completing accuchecks (a meter that measures glucose in whole blood) and failed to properly disinfect glucometers (measures how much sugar is in the blood sample) for one resident (Resident #22). The facility census was 99. Review of the facility's policy titled Hand Hygiene,…
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 · D2024-08-16 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their abuse and neglect policy regarding screening staff members when the facility failed to complete an Employee Disqualification List (EDL - a list that lists staff who are unable to work in long-term care in the state) check and a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals the person cannot work in long-term care)) check for one employee (Registered Nurse (RN) A). The facility had a census of 99. Review of the facility's policy titled Abuse, Neglect, and Exploitation Policy and Procedure, updated 07/2022, showed the following: -The names of all potential employees will be checked against the list maintained by the state of persons who may not be eligible for employment within a long-term care facility; -CNA registry will be checked on all new hires. Staff will print a copy for employee file prior to employment and according to state law; -Facility's are prohibited from employing individuals who have been found guilt of abuse, neglect, mistreatment or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-16 · 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 observation, interview, and record review, the facility failed to provide all necessary activities of daily living (including assistance with meals) to all residents ensure good nutrition when facility staff failed to assist one resident (Resident #17) with eating in a timely fashion. The facility census was 99. 1. Review of Resident #17's face sheet (brief resident profile sheet) showed the following information: -admission date of 11/07/22; -Diagnoses included unspecified protein-calorie malnutrition (a wasting condition resulting from a diet inadequate in either protein or calories or both). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument filled out by facility staff), dated 05/10/24, showed the following: -Moderate cognitive impairment; -Dependent with eating; -At risk for malnutrition. Review of the resident's Nutrition Diagnosis Criteria, dated 05/13/24, showed the resident at risk for malnutrition. Review of the resident's care plan, last revised on 08/14/24, showed the following information: -On 11/22/22, staff…
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 · D2024-08-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure diets were provided as ordered when staff failed to to care plan and provide physician ordered dietary supplements to one resident (Resident #54) who experienced weight loss and one resident (Resident #67) at risk for weight loss. The facility census was 99. Review of the facility's policy titled SNAR (Skin, Nutrition, And At Risk) Policy and Procedure, dated 12/23, showed the following information: -The facility will ensure that the resident maintains, to the extent possible, acceptable parameters of nutritional status to refuse risk of weight loss; -If weight loss/gain of five percent in thirty days is noted on monthly weights, the resident will be added to the weekly SNAR meeting for review; -The dietary manager will bring the list of residents on fluid restrictions, supplements ordered/furnished, and any recommendations that the registered dietician may have made; -The physician will be notified of recommendations made by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-05-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible physical abuse made my one resident (Resident #1) out of seven sampled residents. The facility census was 97. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 01/01/23, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; -Reporting timeframes:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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
Based on record review and interview, the facility failed to keep all residents free from misappropriation when one staff member (Certified Nurse Aide (CNA) A) asked for and then took money from one resident (Resident #1). The facility census 99. On 03/20/24, at approximately 9:45 A.M., the Administrator was notified of the Past Non-Compliance that occurred on 01/24/24. The Administrator immediately started an investigation, notified DHSS by self-report on 03/20/24, at 12:29 P.M., and notified the police on 03/20/24, at 11:47 A.M. All facility staff were notified of required training and completed the computer misappropriation training 03/20/24. CNA A was terminated on 03/20/24 due to not following the facility's policy. The facility implemented continued abuse and neglect training at orientation and quarterly. The staff development nurse will randomly review abuse and neglect competencies with staff on varying shifts. The Administrator or designee will review monthly for the next 90 days and the results will be reviewed in the monthly QAPI (quality assurance performance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-10-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to management and to the State Survey Agency (Department of Health and Senior Services -DHSS) within two hours of the allegations being made when staff were aware of reports of possible abuse involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -All staff will demonstrate familiarity with the signs of abuse, neglect. Any such signs of abuse and neglect will be reported to the Administrator and/or Director of Nursing (DON)/designee immediately. The Administrator, DON or designee will notify the State agency and local law enforcement immediately, but no later than 2 hours after allegation; -The facility Administrator or designee is responsible 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 · E2022-10-03 · 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 complete full and documented investigation in a timely manner when staff were made aware of allegations of possible abuse/neglect involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -Investigation process will proceed after the state notification as indicated and required. The full investigation report of the alleged or suspected violations must be completed and submitted to the state within 5 days after the appropriate abuse reporting time frame guidelines have been followed; -Persons who might have knowledge of the incident are interviewed privately and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-03 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital, including the reason for the transfer, for four residents (Residents #46, #53, #59, and #65). The facility census was 81. Record review of the facility's policy entitled Notice Requirements Before Transfer/Discharge, undated, showed the following information: -It is the policy of the facility to notify the resident and/or their legal guardian before transfer and/or discharge according to state and federal regulations; -Before the facility transfers or discharges a resident, the facility will obtain a physician's order for the transfer and/or discharge; notify the resident and, if known, a family member or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and record the reasons for the transfer or discharge in the resident's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure all residents were free from abuse and neglect when one staff member (LPN K ) reviewed to assist one resident (Resident #71) with his/her bowel regimen and when one staff member (LPN K) spoke to one resident (Resident #32) in a harsh manner that included profane language. The facility's total census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -All staff will demonstrate familiarity with the signs of abuse, neglect; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or service that are necessary to attain or maintain physical,…
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 before2022-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed ensure all residents received supervision and assistance devices to prevent possible elopements when staff failed to check the daily functioning status of one resident's (Resident #42) wanderguard bracelet. The facility had a census of 81. Record review of the facility policy, titled Preventative Action Plan for Wandering/Elopement of Residents, dated April 2020, showed the following: -All residents who enter the facility will have an Elopement Risk Assessment completed at the time of admission; -If the assessment determines the resident to be at risk for exit seeking behavior or attempting an elopement, the facility will begin immediate action to prevent the elopement, such actions included: -Receipt of physician order for a wander guard bracelet if determined by the inter-disciplinary team (IDT - staff members working together, with a common purpose, to set goals, make decisions and share resources and responsibilities); -Resident's care plan updated to reflect the risk for elopement and the approaches 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 · E2019-10-15 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to document and track residents' grievances and failed to make prompt efforts to resolve the residents' grievances for four residents (Resident #31, #40, #54 and #76) out of a selected sample of 20 residents. The facility census was 72. 1. Record review of the facility's policy Right to Voice Grievances undated, showed the following: -An elder, his/her responsible party and family have the right to express a grievance or complaint about care and services provided by the facility without fear of discrimination or reprisal, including grievances with respect to treatment, care or services provided as well as those which have not been provided; -Elders and their families may also report a complaint or grievance in writing to any team member in the facility. The written complaint will be forwarded to the individual responsible for the area of service related to the complaint and/or the facility administrator; -If a grievance or complaint was provided in a written form, a written response will be provided to the individual that…
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 · E2019-10-15 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate less than five percent when the staff made six errors out of 34 opportunities, resulting in an error rate of 17.6%. This affected six residents (Resident #26, Resident #37, Resident #48, Resident #229, Resident #280 and Resident #284). The facility census was 72. 1. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; -Attached disposable needle to pen; -Prime pen prior to each injection to release a small amount of insulin into pen to remove any air bubbles in pen which may affect flow of insulin and cause inaccurate dosage; -Dial…
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 · E2019-10-15 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 residents were free of significant medication errors when staff failed to prime insulin pens prior to administering insulin to three residents (Resident #37, #280, and #284) and failed administer insulin per physicians' orders for two residents (Resident #280 and #284). The facility census was 72. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; -Attached disposable needle to pen; -Prime pen prior to each injection to release a small amount of insulin into pen to remove any air bubbles in pen which may affect flow of insulin and cause inaccurate dosage; -Dial two (2) units 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 · D2019-10-15 · 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 revise care plans for two residents (Resident #49, and Resident #283) to include exit seeking behaviors and use of a seatbelt. The sample size was 20. The facility census was 72. Record review of the facility's policy titled Goals and Objectives, Care Plans, dated April 2009, showed: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Care plan goals and objectives are defined as the desired outcome for a specific resident problem. -When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented; are behaviorally stated; are measureable; and contain timetables to meet…
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 · D2019-10-15 · 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, interview, and record review, the facility failed to obtain a physician order for oxygen for two residents (Resident #27 and Resident #78) in a selected sample of 20 residents. The facility's census was 72. Record review of the facility's Oxygen Administration policy, undated, showed the following: -It is the policy of this community to appropriately provide and monitor oxygen for residents as ordered by the physician. Initiation of oxygen therapy will be performed by a licensed nurse. Direct care staff may reapply the nasal cannula and replace sterile water in the humidifier; -When oxygen is required, an order will be obtained from the physician. 1. Record review of Resident #78's face sheet showed the following: -admitted to the facility on [DATE], re-admitted to the facility on [DATE]; -Diagnoses included pneumonia and high blood pressure. Record review of the resident's care plan, dated 9/12/19 showed the following: -Diagnoses of Chronic Obstructive Pulmonary Disease (COPD); -Administer…
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 · D2019-10-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center for one resident (Resident #34) who received dialysis. A sample of 20 residents was selected for review in a facility with a census of 72. Record review of the facility's End-Stage Renal Disease, Care of a Resident With Policy, revised September 2010, showed residents with end-stage renal disease (ERSD) will be cared for according to currently recognized standards of care. Staff will utilize dialysis communication form to and from dialysis. 1. Record review of Resident #34's face sheet (a general information sheet) showed the following: -The resident admitted to the facility on [DATE], and re-admitted on [DATE]; -Diagnoses included acute kidney failure (when kidneys suddenly become unable to filter waste products from your blood), chronic obstructive pulmonary disease (chronic inflammatory lung disease that…
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 before2019-10-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious contaminants when the facility failed to attach a cap on the end of a PICC (peripherally inserted central catheter) for one resident (Resident #229) in a selected sample of 20 residents. The facility census was 72. According to Clinical Nursing Skills and Techniques 8th edition, [NAME], [NAME], & [NAME], 2014, the rationale that securing connections and the use of protective covers reduces the risk of air emboli (abnormal presence of air in the cardiovascular system), infections and entrance of microorganisms. 1. Record Review of Resident #229 face showed the following -admission date of 10/04/19; -Diagnoses include sepsis (infection that can lead to tissue damage, organ failure, and death), cognitive communication deficit, and dementia (confusion, disorientation). Record review of the resident's admission assessment Minimum Data Set (MDS),…
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 AMERICARE SENIOR LIVING — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 22 homes this chain runs (chain average 3.6★, 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 | Share | Since |
|---|---|---|---|---|
| MONTGOMERY, RICHARD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 10/24/2005 |
| MONTGOMERY, ANNA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 01/01/2013 |
| SCHADE, KYLE | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/01/2021 |
| WINDHAM, ERIC | Individual | W-2 MANAGING EMPLOYEE | — | since 01/08/2019 |
| REIKER, JAMES | Individual | CORPORATE DIRECTOR | — | since 10/24/2005 |
| AMERICARE SYSTEMS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/1981 |
| CROSSON, CLAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/07/2013 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 265799. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-16, 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.