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Springfield Rehabilitation & Health Care Center

2800 South Fort Avenue, Springfield, MO 65807 · For profit - Corporation · 146 certified beds · (417) 882-0035 Medicare & Medicaid certified

Call the home — (417) 882-0035 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Apr 2026
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1718 W Woodland Street · (417) 887-0081 · Call to confirm hours
Pharmacy
2951 S Campbell Ave · (417) 890-7924 · Call to confirm hours
Grocery
1900 W Sunset St Ste A116 · (417) 881-4222 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1222 W Sunset St · (417) 883-2044

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.7%18.1%15.4%worse
Long-stay residents who lose too much weight5.7%5.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.8%1.1%0.9%better
Long-stay residents with a urinary tract infection0.8%2.3%2.0%better
Long-stay residents with depressive symptoms6.0%18.5%6.5%typical
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.3%4.1%3.3%typical
Long-stay residents whose ability to walk worsened20.1%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.9%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%90.9%95.3%typical
Long-stay residents with pressure ulcers2.6%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control19.6%17.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.2%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine99.5%63.5%79.4%better
Short-stay residents rehospitalized after admission20.0%26.0%22.6%better
Short-stay residents with an outpatient ER visit10.0%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.122.111.67better
Long-stay outpatient ER visits per 1,000 resident days0.522.331.80better

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.

54.7% 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 190 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.7%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
68.4%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.7%CMS range 48.5–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.6–14.310.7%Oct 2022–Sep 2024no 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 discharge68.4%56.6%Oct 2024–Sep 2025CMS 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 discharge63.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge98.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.6–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS 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

0.73
RN hours/ resident / day
0.28
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.03
Total nurse hours/ resident / day
0.51
RN hoursweekends
43.6%
Total nursing turnover
11.8%
RN turnover

How full it usually is: this home is certified for 146 beds and averages 121.5 residents a day — about 83% occupied, or roughly 24 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 3.03 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.64 hrs/resident/day on weekends vs 3.19 on weekdays — 17% thinner on weekends. RN hours go from 0.82 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

5
deficiencies at the latest standard inspection (2026-04-10)
18
at the previous standard inspection (2024-05-10)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · E2026-04-10 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete the annual individual performance reviews or evaluations and failed to provide regular in-service education based on these reviews for three certified nurse aides (Certified Nurse Aide (CNA) K, CNA L, and CNA M), out of a sample of six CNAs. The facility census was 117.Review showed the facility did not provide a policy regarding annual individual performance reviews or education for CNAs.1. Review of CNA K's personnel records showed the following:-Hire date of 04/10/24;-Annual performance evaluation due on 04/10/25; -Staff did not document completion of the performance evaluation or education provided to CNA K based on an annual performance evaluation.2. Review of CNA L's personnel records showed the following:-Hire date of 08/22/23;-Annual performance evaluation due on 08/22/25;-Staff did not document completion of the performance evaluation or education provided to CNA L based on an annual performance evaluation.3. Review of CNA M's personnel records showed the following:-Hire date of 09/04/20;-Annual…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff member (Licensed Practical Nurse (LPN) A) spoke in a disrespectful tone and manner when interacting with one resident (Resident #70) resulting in the resident becoming upset. The facility census was 117. Review of the facility policy titled Patient Rights, undated, showed the following:-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.-A facility must protect and promote the rights of each resident. 1. Review of Resident #70's face sheet (a form used to provide resident information at a quick glance) showed the following:-admission date of 09/26/25;-Diagnoses included muscle weakness, age related cognitive decline (a decline on cognitive function due to age), major depressive disorder (a serious mental health condition characterized by at least two weeks of persistent, severe low mood, loss of interest, and low energy), 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 allegation of possible abuse were reported immediately to facility management and to the Department of Health and Senior Services (DHSS) within the required two hour timeframe when staff one resident's (Resident #76) allegation of physical abuse. The facility census was 117.Review of the facility's policy titled Abuse Protection and Response Policy, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of abuse if it meets any of the following criteria: any allegation (or) indication of possible willful infliction of injury to include unexplained bruising; unreasonable confinement to include unwanted restriction of access to all patient areas 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 abuse were investigate when staff failed to complete an investigation of an allegation of physical abuse made by one resident (Resident #76). The facility census was 117.Review of the facility's policy titled Abuse Protection and Response Policy, undated, showed the following:-Abuse, Neglect, and Misappropriation of Patient Property, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center;-All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place. The Administrator or Director of Nurses (DON) will determine the direction of the investigation once notified of alleged incident;-The investigation is conducted immediately under the following circumstances: when it is identified that an alleged…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-10 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all residents received pain management consistent with standards of practice when staff failed to consistently administer pain medications in a timely manner to one resident (Resident #112). The facility census was 117.Review of a facility policy entitled Preparation and General Guidelines: Medication Administration-General Guidelines, revised 02/25/25, showed the following:-The facility has staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions;-Medications are administered in accordance with written orders of the prescriber;-Medications are administered without unnecessary interruptions;-A schedule of routine dose administration times is established by the facility and utilized on the administration records;-Medications are administered within 60 minutes before or after the medication administration record (MAR) scheduled times where possible;-Documented administration should be after the administration.1. Review of Resident #112's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-17 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 implement a pain management program that managed resident pain effectively when staff failed to address one resident's (Resident #1) on-going pain and when staff failed to address one resident's (Resident #2) behavioral indications of pain. The facility census was 121.Review of the facility policy Pain-Clinical Protocol, dated 2001, showed the following:-The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain such as degenerative joint disease, rheumatoid arthritis, osteoporosis, post-stroke syndromes;-The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain;-The staff and physician will identify the characteristics of pain such as location,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 interview and record review, the facility failed to provide respiratory care per standards of practice when the facility failed to provide a physician ordered bipap (noninvasive machine that helps people breathe by delivering pressurized air into their airways) or CPAP (a machine that treats breathing disorders by delivering pressurized air to the airways to keep them open while one sleeps) or document timely steps to acquire needed bipap supplies for one resident (Resident #1). Facility census is 120. Review of the facility policy titled, CPAP/Bipap (continuous positive airway pressure/bilevel positive airway pressure) Support, revised March 2015, showed the following: -Purpose of the machine was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; -Improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; -Promote resident comfort and safety; -Bipap…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 food safe from potential contamination when staff stacked clean dishware inside one another instead of air drying, which could potentially contaminate food served from those items, and failed to keep dented cans separate from other canned goods. The facility census was 115. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled Warewashing Machines Operation, by Safety and Sanitation Best Practice Guidelines, revised November 2017, showed the following information: -Air-dry all items; -Make sure all items are completely dry before stacking to prevent wet-nesting.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident had an indwelling urinary catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. (Staff did not care plan the use of a dignity bag.) Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling urinary catheter; -Total dependence on staff for toileting needs. Observation on 05/09/24, at 4:05 P.M., showed the following: -The resident lay in his/her bed with the resident's urinary catheter hooked to the side of the bed; -The catheter drainage bag was visible from 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0561 — failed to honor residents' choices — pattern
    Honor 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 observation, interview, and record review, the facility failed to promote all residents' right for self-determination of schedule and cares when staff failed to provide showers as preferred and care planned for nine residents (Resident #9, #21, #23, #55, #108, #33, #8, #15, and #11) of 29 residents sampled. The facility census was 115. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of residents' skin. The policy did not address the scheduling of showers/baths. 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -readmission date of 07/19/20; -Diagnoses include stroke, hemiplegia (paralyzed on one side of the body), anxiety disorder (feelings of worry, anger or fear), and depression (feelings of sadness). Review of the resident's quarterly Minimum Data Set (MDS - 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · E2024-05-10 · tag F0623 — pattern
    Provide 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 record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital that included the reason for the transfer, date of transfer, and destination of transfer for three residents (Resident #100, Resident #5 and Resident #8) out of 29 sampled residents. The facility census was 115. Review of the facility provided copy of Hospital Transfer Checklist, showed the following: -Fill out Interact Nursing Home to Hospital Transfer under observation, print and send with the resident. 1. Review of Resident #100's progress note, dated 01/23/24, showed the following: -The resident was reported to be combative, agitated, yelling, and cursing at staff and refusing cares; -Order received to send resident to hospital for evaluation and treatment; -Staff called daughter and informed of nurse practitioner's (NP) order; -Resident was transferred to the hospital. (Staff did not document staff provided the resident or representative with a hospital transfer notice.) Review of the resident's medical record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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 2. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; -Diagnoses included personal history of frequent urinary tract infections (UTI's), neuromuscular dysfunction of bladder (when the brain does not communicate with the bladder), and retention of urine (when one is unable to completely empty the bladder). Review of the resident's care plan, dated 06/11/22, showed the following: -Resident does use an indwelling catheter; -Staff are expected to maintain, clean, and position catheter tubing and bag below level of bladder and provide daily care. Review of the resident's annual MDS, dated [DATE], showed the following: -Resident required an indwelling catheter; -Toileting hygiene showed resident as totally dependent on staff for toileting needs. Observation on 05/09/24, at approximately 4:05 P.M., showed the following: -The resident lay in his/her bed and the catheter was hooked to the side of the bed; -The catheter touched the floor. Based on observation, interview, and record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 observation, interview, and record review, the facility failed to ensure pharmaceutical services with accurate documentation and storage for the emergency kit (E-Kit - kits containing commonly prescribed medications for emergency use) when medication lock tags failed to match the form titled All E-Kit Lock Registration for three of five E-Kit boxes. The facility census was 115. Review of the facility policy titled Medication Storage in the Facility, dated 01/01/19, showed the following: -Medications and biologics are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including requirements of good manufacturing practices. Medications are kept in these containers; -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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, record review and interview the facility failed to ensure that the medication error rate was not 5 percent or greater, when staff failed to prime insulin pens (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) for three residents (Residents #220, #215, and #10) of 29 opportunities observed during medication pass (10% error rate). The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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 staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; failure to do so may result in administering too much or too little insulin) the insulin pens before administering insulin to three residents (Residents #220 #215, and #10) of four residents observed during insulin administration. The facility census was 115. Review of the Instructions for Using Insulin Lispro (rapid acting insulin) KwikPen, revised 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops and 0 is seen in the dose window. Hold the dose…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medications were stored safely and securely when staff failed to lock medication and treatment carts when unattended by authorized personnel. The facility had a census of 115. Review of the facility policy titled Medication Storage in the Facility, revised 01/01/19, showed the following information: -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications; -Medication rooms, carts, and medication supplies are to be locked when not attended by persons with authorized access. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: -All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/tech. 1. Observation on 05/08/24, at 10:48 A.M., showed C hall medication cart, unlocked and accessible with no certified medication technician (CMT) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 maintain an effective infection control program to prevent the risk of contamination and spread of infection when staff failed to complete proper hand hygiene during incontinent care for one resident (Resident #81) and during urinary catheter (bag that collects urine from the tube that attaches to a catheter (tube) that is inside the bladder) care for one resident (Resident #61). The facility also failed to protect clean laundry from possible contamination. The facility census was 115. Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, showed the following information: -Hand hygiene is the primary means to prevent the spread of infections; -All personnel should be trained and inserviced on the importance of hand hygiene and shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections; -Hand hygiene products and supplies shall be readily accessible and convenient for 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0919 — failed to provide a working call system — pattern
    Make 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 5. Review of Resident #8's face sheet showed the following: -admission date of 06/22/23; -Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), history of falling, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and generalized anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Used walker and/or wheelchair for mobility; -Independent with toileting hygiene; -Independent with upper and lower body dressing; -Supervision with transferring from bed, chair, or toilet. Review of the resident's care plan, reviewed on 05/04/24, showed the following: -Resident at increased risk for falls related to Parkinson's, poor safety awareness, and history off falls; -Staff should re-educate resident to call for assistance when needed; -Staff should keep call light within reach. Observation…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 determine all residents who self-administered medications were clinically appropriate to do so when staff left medications at bedside for one resident (Resident #99) to administer to his/herself unattended without an assessment, order, or care plan to do so. The facility census was 115. Review of the facility policy titled Specific Medication Administration Procedures, revised 01/01/19, showed the following information: -Administer medication and remain with resident while medication is swallowed. Do not leave medications at bedside, unless specifically ordered by prescriber; -Chart medication administration on Medication Administration Record (MAR) immediately following each resident's medication administration. 1. Review of Resident #99's face sheet (brief information sheet about the resident) showed the following: -admission date of 05/29/23; -Diagnoses included post traumatic stress disorder (PTSD - disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event),…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to notify and coordinate with the State-designated authority when one resident (Resident #100), a previously identified by the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings) as having a mental disorder, experienced a significant change. The facility census was 115. Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), dated 11/2016, showed the center should refer any patient for Level II resident review…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 ensure residents who required assistance with showers received the necessary assistance with showers when the facility failed to ensure one resident (Residents #2), dependent on staff for grooming, received regular showers and appropriate grooming. The facility census was 115. Review of the facility's policy titled Bath, Shower/Tub, revised February 2018, showed the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Review showed the facility did not provide a policy pertaining to the scheduling of showers/bathing. 1. Review of Resident #2's face sheet showed the following: -admission date of 05/03/02; -Diagnoses included heart failure and Stage IV (full thickness skin loss with extensive tissue destruction, tissue death or damage to muscle, bone, or supporting structures) pressure ulcer of the sacral region (the triangular-shaped bone at the base of the spine). Review of the resident's care plan, revised 03/13/24, showed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, record review, and observation, the facility failed to ensure staff followed physician orders and accurately documented the implementation of physician orders when staff failed to apply tubi grips (an elasticated tubular bandage designed to provide support for sprains, strains, and swelling) as ordered for one resident (Resident #59). A sample of 29 residents was selected for review. The facility census was 115. Review of the facility's policy titled, Physician Orders Policy, undated, showed the following information: -Orders will be received by licensed nursing staff; -Orders will be reviewed and if there are questions, clarification will be obtained from the physician; -If no questions or questions are clarified, orders will be implemented. 1. Review of Resident #59's face sheet showed the following information: -readmission date of 03/25/24; -Diagnoses included chronic respiratory failure with hypoxia (the body doesn't have enough oxygen in your blood), high blood pressure. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as possible when staff transferred one resident (Resident #61) without the use of the gait belt. The facility census was 115. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 07/17, showed the following information: -In order to protect the safety and well-being of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Staff will document resident transferring and lifting needs in the care plan; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices; -Staff will be observed for competency in using mechanical lifts and observed periodically…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea) where then a tube is placed into the hole to keep it open for breathing) care following professional standards of practice for one resident (Resident #59). The facility census was 115. Review of the facility's policy titled Tracheostomy Care Procedure, undated, showed the following information: -The purpose of the procedure was to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas; -Aseptic technique (method used to prevent contamination in procedures where a sterile field is required) must be used; -Gloves must be used on both hands during any or all manipulation of the tracheostomy; -Sterile gloves must be used during aseptic procedures, a mask and eyewear must be worn; -Tracheostomy tubes should be changed as ordered and as needed; -A replacement tracheostomy tube, a suction machine, supply for suction catheters, exam and sterile gloves, and flush solution must be available…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 have an effective system in place to ensure accommodation of residents' meal preferences when staff served one resident (Resident #84) meals that did not reflect the resident's requested food preferences. The facility census was 115. Review showed the facility did not provide a policy regarding resident food preferences. 1. Review of the Resident #84's face sheet (a document showing the resident's information at a quick glance) showed the following information: -readmission date of 04/26/24; -Diagnoses included congestive heart failure (a condition in which the heart doesn't pump blood as it should), respiratory failure with hypoxia (a condition where one does not have enough oxygen in the tissues of the body), type two diabetes, and dysphagia (difficulty swallowing). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff), dated 01/12/24, showed the following information: -Cognitively intact; -Can eat independently. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity/respect when one staff member (Housekeeper G) yelled at one resident (Resident # 3) in the dining room of the facility. A sample of seven residents selected for review in a facility with a census of 119. Review of the facility policy titled Quality of Life - Dignity, undated, showed the following information: -Residents shall be treated with dignity and respect at all times; -Residents shall be assisted in maintaining and enhancing his/her self-esteem and self-worth; -Staff shall speak respectfully to residents at all times. 1. Review of Resident # 3's face sheet (brief resident profile sheet) showed the following information: -admission date of 10/17/22; -Diagnoses included multiple sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord), left side hemiplegia (paralysis), and chronic urinary tract infections. Review of the resident's quarterly Minimum Data Set (MDS - a federally…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 maintain an effective infection prevent and conrol program when staff failed complete appropriate hand hygiene and glove usage while providing incontinent care for two residents (Resident # 1 and Resident # 2). The facility census was 119. Review of the facility policy, titled Handwashing/Hand Hygiene, undated, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub before and after direct contact with residents; -Use an alcohol-based hand rub before donning gloves; -Use an alcohol-based hand rub before moving from a contaminated body site to a clean body site during resident care; -Use an alcohol-based hand rub after contact with bodily fluids; -Use an alcohol-based hand rub after removing gloves; -Hand hygiene is the final step…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-01-27 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN: Medicare requires SNFs to issue a SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for one resident (Resident #20) out of 19 sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for one resident (Resident #187) outside the sample. The facility's census was 93. 1. Record review of the facility's policy titled, Beneficiary Notices of Non-Coverage, dated 4/1/18, showed: - NHC will provide proper notification of non-coverage decisions to Medicare…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NATIONAL HEALTHCARE CORPORATION — 69 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 →

RatingThis homeChain avg
Overall 5 of 54.0+1.0 vs chain
Health inspection 4 of 53.5+0.5 vs chain
Staffing 4 of 53.5+0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 68 homes this chain runs (chain average 4.0★, per CMS)
1 of 5NHC Healthcare - MauldinGreenville, SC 2 of 5NHC Healthcare - CharlestonCharleston, SC 2 of 5NHC Healthcare, GlasgowGlasgow, KY 2 of 5Nhc Healthcare RossvilleRossville, GA 2 of 5Nhc Healthcare, AnnistonAnniston, AL 2 of 5Nhc Healthcare, FranklinFranklin, TN 2 of 5Nhc Healthcare, JoplinJoplin, MO 2 of 5Nhc Healthcare, SpringfieldSpringfield, TN 2 of 5Osage Beach Rehabilitation And Health Care CenterOsage Beach, MO 2 of 5White Oak Manor-ShelbyShelby, NC 3 of 5Adamsplace, LLCMurfreesboro, TN 3 of 5NHC Healthcare - GreenwoodGreenwood, SC 3 of 5Nhc Healthcare, Ft SandersKnoxville, TN 3 of 5Nhc Healthcare, HendersonvilleHendersonville, TN 3 of 5Nhc Healthcare, KnoxvilleKnoxville, TN 3 of 5Nhc Healthcare, LewisburgLewisburg, TN 3 of 5Nhc Healthcare, PulaskiPulaski, TN 3 of 5Nhc Healthcare, SmithvilleSmithville, TN 3 of 5Nhc Healthcare, SpartaSparta, TN 3 of 5Nhc Healthcare, TullahomaTullahoma, TN 3 of 5The Health Center At Richland PlaceNashville, TN 3 of 5The MeadowsNashville, TN 3 of 5White Oak Manor - YorkYork, SC 4 of 5NHC HealthCare - North AugustaNorth Augusta, SC 4 of 5NHC Healthcare - BlufftonOkatie, SC 4 of 5NHC Healthcare - Garden CityGarden City, SC 4 of 5NHC Healthcare - LexingtonWest Columbia, SC 4 of 5Nhc Healthcare, ChattanoogaChattanooga, TN 4 of 5Nhc Healthcare, ColumbiaColumbia, TN 4 of 5Nhc Healthcare, DeslogeDesloge, MO 4 of 5Nhc Healthcare, Maryland HeightsMaryland Heights, MO 4 of 5Nhc Healthcare, MilanMilan, TN 4 of 5Nhc Healthcare, Oak RidgeOak Ridge, TN 4 of 5Nhc Healthcare, OakwoodLewisburg, TN 4 of 5Nhc Healthcare, St CharlesSaint Charles, MO 4 of 5Nhc Place At Cool SpringsFranklin, TN 4 of 5White Oak Manor - CharlestonCharleston, SC 4 of 5White Oak Manor - SpartanburgSpartanburg, SC 5 of 5HeartlandNashville, TN 5 of 5Holston Health & Rehabilitation CenterKnoxville, TN

Showing 40 of 68; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Investor-owned

CMS ownership filings flag an owner of this facility as an investment firm. That’s a fact worth knowing about who ultimately profits from the home. Read the inspection and staffing record above on its own merits.

  • MORGAN STANLEY — investment firm · 5.30% share · 5% Or Greater Indirect Ownership Interest
  • VANGUARD GROUP INC — investment firm · 9.00% share · 5% Or Greater Indirect Ownership Interest

Source: CMS SNF ownership filings (PECOS). These flags are self-reported and undercount — federal auditors (GAO) and researchers find CMS captures only a fraction of true private-equity and REIT ties, so the absence of a flag on other homes is not proof they lack investor owners. How investor ownership affects care →

Owner / managerTypeRoleSince
NHC/DELAWARE INCOrganizationDIRECT OWNERSHIP INTERESTsince 12/01/2010
MORGAN STANLEY INSTITUTIONAL ADVISORS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/08/2024
RECTOR, MELVINIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2010
NATIONAL HEALTHCARE CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2024
NHC-OP LPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2024
BETHMANN, SHERIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/16/2024
DODSON, VICKIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2019
HARMON, LYSANDRAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/10/2019
KIDD, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
LACEY, TROYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2020
USSERY, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2010
BLACKROCK INCOrganizationADP OF THE SNFsince 03/20/2019
DIMENSIONAL FUND ADVISORS LPOrganizationADP OF THE SNFsince 03/07/2023
MORGAN STANLEYOrganizationADP OF THE SNFsince 11/08/2024
NATIONAL HEALTH CORPORATIONOrganizationADP OF THE SNFsince 01/02/2024
VANGUARD GROUP INCOrganizationADP OF THE SNFsince 03/27/2017

CMS files one row per role, so the 24 rows in the source record cover these 16 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.

9 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.

$11.8M
Net patient revenuemost recent cost report
+2.6%
Operating marginrevenue minus expenses
$922K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 9%Other / private 33%

This home reported $922K 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

$277per resident / day
operating cost
$8,427per month
≈ monthly operating cost
$285per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

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 265157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.

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