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Life Care Center Of Sullivan

875 Dunsford Drive, Sullivan, MO 63080 · For profit - Corporation · 120 certified beds · (573) 468-3128 Medicare & Medicaid certified

Call the home — (573) 468-3128 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)
  • about 17% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
965 Mattox Dr · (573) 860-6000 · Call to confirm hours
Pharmacy
Walgreens1.2 mi
6 E Springfield Rd · (573) 468-6464 · Call to confirm hours
Grocery
45 N Clark St · (573) 468-4191 · Call to confirm hours
Park
State Route 106, six miles west · Typically dawn to dusk
Place of worship

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 3 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 held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased7.0%18.1%15.4%better
Long-stay residents who lose too much weight12.9%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.1%0.9%better
Long-stay residents with a urinary tract infection1.9%2.3%2.0%typical
Long-stay residents with depressive symptoms6.1%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 injury3.6%4.1%3.3%typical
Long-stay residents whose ability to walk worsened8.5%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine93.5%90.9%95.3%typical
Long-stay residents with pressure ulcers2.6%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control14.9%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.8%23.5%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.7%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine38.2%63.5%79.4%worse
Short-stay residents rehospitalized after admission28.5%26.0%22.6%worse
Short-stay residents with an outpatient ER visit17.4%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.292.111.67worse
Long-stay outpatient ER visits per 1,000 resident days4.642.331.80worse

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.

51.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.6%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
87.2%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 87.2% 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 39 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.6%CMS range 39.8–59.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.3–15.510.7%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 discharge87.2%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 discharge66.7%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 discharge59.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened7.9%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 hospitalization6.3%CMS range 3.8–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

0.49
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.95
Aide hours/ resident / day
3.32
Total nurse hours/ resident / day
0.36
RN hoursweekends
57.7%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 73.4 residents a day — about 61% occupied, or roughly 47 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.95 hrs/resident/day on weekends vs 3.47 on weekdays — 15% thinner on weekends. RN hours go from 0.55 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-03-19)
7
at the previous standard inspection (2024-10-04)

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2025-06-16 · 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

    Based on observation, interview and record review, facility staff failed to provide timely treatment to one resident (Resident #1) when he/she sustained a burn injury to his/her right thigh on 06/02/25 from hot coffee and staff did not document any treatment interventions for the burn until 06/04/25. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for how to address a change in a resident's condition after a burn injury. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate cognitive impairment, independent with eating, bed mobility, and transfers. Review of the resident's progress notes, dated 06/02/25 at 5:04 P.M., showed Licensed Practical Nurse (LPN) C documented the resident spilled hot coffee on his/her right leg, no blistering observed but there is a red blotchy area, will continue to monitor for skin changes. Staff did not document they administered any treatment to the resident's leg/thigh. 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 · E2026-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, facility staff failed to provide care to meet the basic hygiene needs for five residents (Resident #2, #4, #5, #6, and #7) out of seven sampled residents who required assistance with Activities of Daily Living. The facility's census was 82. 1. Review of the facility's Activities of Daily Living (ADL) policy, revised 09/04/25, showed the residents will receive assistance as needed to complete ADLs. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's shower schedule showed each resident is scheduled to be assisted with a bath/shower twice per week by facility staff. 2. Review of Resident #2''s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Impairment to one side lower extremity (hip, knee, ankle, foot); -Required set-up assistance from staff for personal hygiene;-Required…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, facility staff failed to maintain professional standards of care, when staff failed to transcribe a wound treatment order from the hospital for one resident (Resident #1), and failed to document wound care and treatments as directed by the physician for three residents (Resident #1, #2, and #3) out of three sampled residents with wounds. The facility's census was 82.1. Review of the facility's Physician Orders policy, revised 02/11/26, showed the facility is to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Physician orders include medications and treatments. Review of the facility's Treatment Orders policy, revised 05/15/26, showed treatment orders are written per physician orders. The physician writes an order that includes the following: site of wound, name of cleanser, name of ointment, type of dressing and number of times to perform the treatment/duration of treatment. The physician order…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-04-22 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review facility staff failed to obtain orders and complete assessments for one resident (Resident #1's) surgical wound. The facility census was 67.1. Review of the facility's treatment order policy, reviewed 6/12/25, showed treatment orders are written per physician orders. If a resident has multiple wound sites, a complete and separate treatment order must be written for each site. The physician writes an order that includes the following: site of wound, name of cleanser, name of ointment, type of dressing and number of times to perform the treatment/duration of treatment.Review of the facility's Physician Orders, revised 2/11/26, showed a physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident.2. Review of the resident's face sheet showed the resident admitted to the facility on [DATE].Review of the resident's hospital Discharge summary, dated [DATE], showed a diagnosis of gangrene (a serious,…

    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 · Ecited before2026-03-19 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to one of one residents (Resident #40) who received a pureed diet and 10 residents who received mechanically altered diets. The facility census was 76.1. Review of the facility's policy titled Food Preparation, revised 04/29/25, showed the policy directed for the Director of Food and Nutrition Services to provide recipes and the recipes were to be followed by food service associates Review also showed the policy directed staff to prepare menu items in accordance with the menu, recipes and production sheets. 2. Review of the facility's lunch menus dated 03/17/26 (Week 4, Day 24), showed staff directed to provide the residents who received a pureed diet with a #10 (3.2 ounces (oz.)) scoop of pureed fish, and a #8 (four oz.) scoop of pureed seasoned beans. Observation on 03/17/26 at 12:30 P.M., showed [NAME] A served Resident #40 a #16 (two oz.) scoop of pureed fish (1.2 oz. less than directed by the menu) and a #16 scoop of beans (two oz.…

    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 before2026-03-19 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to educate and offer the Coronavirus disease 2019 (COVID-19) (a respiratory disease that can cause severe illness) vaccination for four residents (Resident #7, #10, #21 and #66) out of five sampled residents. The facility census was 76.1. Review of the facility's COVID-19 (SARS-CoV) Vaccination Program Policy for Residents, revised 11/25/25, showed the facility will educate residents or the resident representative regarding benefits and potential side effects associated with the Covid-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum the following: -The resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; -Each dose of COVID-19 vaccine administered to the resident; -If the resident did not receive the Covid-19 vaccine due to 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-19 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, facility failed to conduct regular maintenance of all bedrails to identify areas of possible entrapment for 9 (Resident #1, #2, #5, #7, #9, #11, #12, #26, #70) of 11 sampled residents who used bed rails. The facility census was 76.1. Review of the facility's policy titled Bed Rails-Safe and Effective Use, dated 09/3/25, showed if bed rails are determined appropriate for use with a resident, a reassessment will be assessed at a minimum of quarterly or potentially with a change of condition utilizing the Evaluation for Use of Bed Rails form. When installing or maintaining bedrails, the Maintenance Department will follow the manufacturer's recommendations and specifications. 2. Review of Resident #1's admission Minimal Data Set (MDS), a federally mandated assessment tool, dated 02/6/26, showed staff assessed the resident as: -Cognitively intact; -Functional impairment on both sides; -Diagnosis of stroke; -Paraplegia (paralysis affecting the legs); 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to notify the physician and resident representative in a timely manner of a change in condition, when one resident (Resident #1) spilled coffee on his/her thigh and resulted in a significant burn injury. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for when to notify the Physician/Resident Representative of an injury, or change in a resident's condition. Review of the facility's interact Signs and Symptoms guide (an electronic quality improvement communication tool designed to improve the identification, evaluation, and communication about changes in resident status), dated 2014, showed staff are directed to document an immediate entry for any burn other than a minor first degree burn with no significant pain, or a non-immediate entry for minor first degree burn in the past twenty-four hours. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate…

    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 · D2025-06-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, facility staff failed to review and revise comprehensive care plans to include interventions for one resident (Resident #1) after he/she sustained burns to his/her thigh from hot liquids, and smoking interventions for one resident (Resident #2) out of three sampled residents. The facility's census was 67. 1. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 09/11/24, showed staff are directed as follows: -A Comprehensive Care Plan must be reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments; -The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; -When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. 2. Review of Resident #1's quarterly 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 struck Resident #1 in the face. The facility census was 66. 1. Review of the facility's Abuse prevention policy, dated 6/17/24, showed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, assess, and care plan for appropriate interventions and monitor residents with needs and behaviors which might lead to conflict or neglect such as verbally aggressive behaviors and physically aggressive behaviors. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/13/25, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Alzheimer's and dementia; -No mood disorders or behaviors. Review of the resident's care plan, reviewed 3/16/25, showed staff assessed the resident at risk for changes in mood or behavior due 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-04 · 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 staff failed to properly wash and sanitize soiled dishes to prevent cross-contamination. Facility staff failed to allow dishes to air dry prior to storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to ensure waste containers in food preparation and utensil washing areas were covered when not in actual use. The facility census was 69. 1. Review of the facility's High-Temperature Dish Machine policy, dated 11/30/10, showed direction for the final sanitizing rinse temperature of the machine to be 180 degrees Fahrenheit (dF) and a booster heater is required to reach the 180 dF temperature for the rinse cycle. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed: -Food and Nutrition Services associates are to be trained in the proper use, cleaning and sanitation of all equipment and utensils; -Equipment of the type and in the amount necessary for the proper preparation, serving and storing of food and for proper dishwashing are provided and maintained in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-10-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to maintain a clean, safe, comfortable, and homelike environment when staff failed to adequately clean and properly maintain three of the four shower rooms. The facility census was 69. 1. Review of the facility's policy titled Housekeeping General Policy, revised 06/12/24, showed it is the responsibility of the Executive Director through the Environmental Service Director to assure that Housekeeping Policies are implemented and followed. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Housekeeping personnel are required to attend training classes. Review of the facility's policy titled Housekeeping Services, revised 06/04/24, showed the facility will provide a safe, clean, comfortable, and homelike environment. The facility must follow standard practices for cleaning and disinfection of surfaces and equipment in accordance with Center for Disease and Prevention (CDC) guidelines. The environmental services supervisor will…

    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 · E2024-10-04 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to document they provide restorative therapy for two residents (Resident #9 and #41). The facility census was 69. 1. Review of the facility's policy titled Restorative Nursing dated 11/30/23, showed staff are instructed to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Restorative indicators may be identified by multiple disciplines utilizing various assessments, physician orders, progress notes, environmental factors, caregiver conversations, and another means of communication. Communicate the restorative care plan and care directives to other members of the interdisciplinary (IDT) team. The trained Certified Nurse Aide (CNA) will document provided techniques per the restorative care plan in the medical record. The licensed nurse will conduct an evaluation on…

    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 · Ecited before2024-10-04 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received regular and easy to chew (EC) diets. The facility census was 69. 1. Review of the facility's Menus, Substitutions, and Alternatives policy, dated 04/30/24, showed Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value. 2. Review of the facility menus dated 10/02/24 (Week 4, Day 25), showed the menus directed staff to serve one serving of sweet and sour meatballs, a #8 (four ounce) scoop of steamed rice, and a six ounce portion of Soup Da Jour at the lunch meal to residents who received regular diets. Review of the recipe for the sweet and sour meatballs, dated 03/20/24, showed the recipe directed staff to staff 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-04 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to educate and offer the Covid-19 (a disease caused by a novel coronavirus) vaccination in accordance with current guidelines and policy for three (Residents #39, #57 and #61) of five sampled residents. The facility census was 69. 1. Review of the facility's policy Resident Vaccination, review dated 12/4/23, showed the facility in conjunction with the Public Health Authorities and CDC (Centers for Disease Control) guidelines will provide immunizations to older adults that are recommended and ordered by a physician once determined to be eligible and without contraindications. The facility should screen individuals prior to offering the COVID-19 vaccination to check for the following: Prior vaccination status; The presence of medical precautions and contraindication. Education must be provided to the resident and/or resident's responsible party regarding benefits and potential side effects of immunization. The resident or resident's representative has the opportunity to refuse immunizations. Review of the Centers for Disease…

    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 · D2024-10-04 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to ensure two Nurse Aides (NA)'s (NA M and NA N) of fourteen sampled completed the nurse aide training program within four months of his/her hire date. The facility census was 69. 1. Review of the facility's policy titled Nurse Aide Requirements, undated, showed the facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis. 2. Review of the facility's Active Payroll for September 2024 showed NA M with a hire date of 02/20/24, and NA N with a hire date of 01/11/24. 3. During an interview on 10/04/24 at 3:04 P.M., the Staffing Coordinator said NA M and NA N were scheduled to re-take the Certified Nurse Aide (CNA) test. The Staffing Coordinator said NA M and NA N were allowed to continue to work until they retook the test. During an interview on 10/04/24 at 4:00 P.M., NA M said he/she failed the CNA test. NA M said he/she is still doing the job of a CNA including providing all cares. NA M said he/she is not aware of any limitations and is doing the same duties…

    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 · Ecited before2023-08-17 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to keep resident rooms and common areas clean and in good repair. The facility census was 69. 1. Review of the facility's policy titled, Resident Belongings and Home like Environment, reviewed 7/17/2023, showed it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. Review of the facility's policy titled, Residents Rights , reviewed 10/6/2023, showed the resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. 2. Observation on 08/14/23 at 12:12 P.M., showed an approximate 12 inch (in) by (x) 12 in broken floor and wall tile in the dining room. Additional observation showed missing trim and chair railing in multiple places. Observations from 08/14/23 through 08/17/23, showed the bathroom wall in room [ROOM…

    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 · Ecited before2023-08-17 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to obtain labs in a timely manner for one resident (Resident #37), and failed to produce documentation for pharmacist recommended interventions for one resident (Resident #60). Additionally, staff failed to perform blood sugar tests in a manner to obtain an accurate reading for four residents (#17, #23, #30, and #32). The facility census was 69. 1. Review of the facility's policy titled, Laboratory services, dated 3/21/23, showed staff are directed to do the following: -The facility will ensure that laboratory services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnoses, and treatment, and the facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside source; -The facility will ensure that laboratory reports are present in the residents' 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when staff failed to properly store disposable razors in one of two shower rooms and left one resident (Resident #30) alone in the shower room with the disposable razors on the counter. Additionally, staff failed to properly propel five residents (Resident #33, #47, #55, #333, and one unidentified resident) in wheelchairs in a manner to prevent accidents. The facility census was 69. 1. Review of the facility's policy titled, Incident, dated 8/15/23, showed the facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 2. Observation on 8/16/23 at 8:17 A.M., showed the spa room doors where left unlocked and unattended with an open box of disposable razors on the counter. Further 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-17 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one (Resident #21) of two sampled residents received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to provide ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 69. 1. Review of the facility's dialysis contract, signed 11/13/17, showed both parties shall ensure that there is documented evidence of collaboration of care and communication between long term care facility and End-Stage Renal Disease (ESRD) Dialysis unit. Review of the facility's policy titled, Hemodialysis Offsite, dated 4/17/23, showed staff are directed to do the following: -The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with professional standards of practice. This includes: -Ongoing assessment of each residents' condition…

    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 · E2023-08-17 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. Additionally staff failed to assist seven residents (Resident #15, #30, #54, #57, #58, #63 and #221) with showers, assist one resident (Resident #21) to bed, and provide meal assistance for one dependent resident (Resident #44). The facility census was 69. 1. Review of the Facility Assessment, dated 6/15/23, showed facility staff documented the following staffing requirements are needed on a 24 hour basis to meet the needs of their residents: -Registered Nurse (RN): 6; -Licensed Practical Nurses (LPN): 6; -Certified Nursing Assistant (CNA): 16; 2. Review of the staff schedule, dated 8/14/23 through 8/17/23 showed: -08/14/23: -RN: 3; -LPN: 4; CNA: 14; -08/15/23: RN: 3; LPN: 6; CNA: 15; -08/16/23: RN: 3; LPN: 6; CNA: 12; -08/17/23: RN: 7; LPN: 7; CNA: 15. 3. Review of the policies provided by the facility showed no bathing or shower…

    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 · E2023-08-17 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #12), and failed to ensure as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #13 and #58). The facility census was 69. 1. Review of the facility's policy titled, Pharmacy services and procedures manual, Psychotropic medications use, revised 10/2022, showed staff were directed to do the following: -PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month; -For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer then 14 days is appropriate, the attending physician can extend 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-17 · 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 facility staff failed to ensure medications were stored in a safe and effective manner for three out of four medication carts, and failed to discard expired medications from one of two medication storage rooms and one of one over the counter medication storage cabinet. The facility census was 69. 1. Review of the facility's Storage and Expiration Dating of Medications Policy, dated 7/21/22, showed the policy directs staff as follows: -Facility should ensure that medications and biologicals that: (1) have an expired date on the label, (2) have been retained longer then recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; -Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received; -Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.…

    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 · E2023-08-17 · 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, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash or sanitize their hands in between glove changes during perineal care and wiped multiple times with the same area of the wipe for two (Resident #2 and #72) of two sampled residents, failed to wash or sanitize their hands in between gloves changes during wound care for one (Resident #59) of two sampled residents, failed to use a barrier for the glucometer and to properly clean and disinfect the glucometer, failed to use appropriate hand hygiene before and after blood sugar checks for four (Resident #17, #23, #30, and #32) of four sampled residents, before and after giving insulin for two (Resident #17 and #30) of two sampled residents, and before and after medication administration for three (Resident #39, #40, and #48) of three sampled residents. The facility census was 69. 1. Review of the facility's 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-17 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for seven residents (Resident #12, #33, #44, #49, #58, #220 and #221), obtain physicians orders for three residents (Resident #33, #49 and #58), and update care plans for four residents (Resident #33, #44, #49 and #220) who utilized bed rails. Additionally, staff utilized bed rails for one resident (Resident #49) who declined bed rail use due to potential risks. The facility census was 69. 1. Review of the facility's policy titled, Bed inspection and maintenance and bed rail installation, revised 12/12/2022, showed staff were directed to do the following: -When installing or maintaining bed rails, the maintenance department will follow the manufacturer's recommendations and specifications. All resident beds will be maintained according to the schedule and procedures of the preventative maintenance program; -Quarterly inspections of the seven zones of entrapment are required for all beds and when there 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · 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, facility staff failed to accurately complete and or update a new diagnosis within the Pre-admission Screening and Resident Review (PASARR) documentation to incorporate the recommendations into resident assessment and care plan for two out of four sampled residents (Resident #12 and #15). The facility census was 69. 1. Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR), revised 10/06/2022, showed staff are directed to do the following: -The facility will ensure that potential admissions are to be screened for possible serious mental disorders (MD) or intellectual disabilities (ID) and related conditions. The initial pre-screening is referred to as PASARR Level 1, and is completed prior to admission to a nursing facility. A negative Level 1 screen permits admission to process unless a possible serious MD or ID arises later; -A positive Level 1 screen necessitated an in-depth evaluation of the individual by the state-designated…

    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 · D2023-08-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility staff failed to prepare pureed foods in accordance with standardized recipes and in a manner that conserved nutritive value, flavor and appearance. The facility census was 69. 1. Review of the facility's policy titled, Therapeutic and modified diets, showed staff were directed as follows: -Therapeutic diets will be provided as prescribed by the attending physician or per state guidelines; -The intent of this is to ensure the resident receives and consumes food in the appropriate form and/or the appropriate nutrient content as prescribed by a physician to support the treatment and plan of care for each resident and in accordance with his/her goals. A modified texture diet is specifically prepared to alter the consistency of food and/or beverage in order to facilitate oral intake. Food service associates alter foods for modified textures such as grinding or pureeing food before serving to the residents in accordance with facility established guidelines and standardized recipes. Review of the recipe for pureed garlic pepper…

    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
  • No harm found · C2024-10-04 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to ensure the three most recent years of survey results were posted and readily accessible to residents, family members or representatives of residents. The facility census was 69. 1. Review of the facility's policy titled Availability of Survey Results, dated 05/23/19, showed results from the most recent state surveys must be available and easily accessible to the residents and family members within the facility. Place readily accessible. This is a place such as a lobby or other area frequented by most residents, visitors or other individual where individuals wishing to examine survey results do not have to ask to see them. 2. Observation on 10/01/24 at 9:43 A.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 3. Observation on 10/02/24 at 5:03 P.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 4. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-17 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and the resident census on a daily basis. The facility census was 69. 1. Review of the facility's staffing policy, revised 3/9/2021, showed: -The facility posts daily staffing information in a clear readable format in a prominent place that is easily accessible to residents and visitors at any given time. -The daily posting must include: Facility name, current date, total number and actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident are per shift. i. Registered nurses ii. Licensed practical nurses or licensed vocational nurses iii. Certified nurses aides Review of the facility's Daily Staff Postings from 8/14/23 through 8/17/32 showed the nurse staff posting board at the main entrance and both nurses station did not contain the total number of staff, per shift, licensed 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.

    Nursing and Physician Services 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 LIFE CARE CENTERS OF AMERICA — 194 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 4 of 53.4+0.6 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 2 of 53.3-1.3 vs chain
Quality measures 3 of 54.5-1.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
TAYLOR, MATTHEWIndividualW-2 MANAGING EMPLOYEEsince 09/15/2021
CROSS, CINDYIndividualCORPORATE OFFICERsince 09/06/2002
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/06/2002
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/25/2002

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$7.0M
Net patient revenuemost recent cost report
-7.8%
Operating marginrevenue minus expenses
$1.3M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 7%Other / private 34%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$287per resident / day
operating cost
$8,719per month
≈ monthly operating cost
$266per 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 265340. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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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