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Aspire Senior Living Warsaw

1609 Sunchase Drive, Warsaw, MO 65355 · For profit - Limited Liability company · 90 certified beds · (660) 438-2970 Medicare & Medicaid certified

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Flagged for abuseResident-funds citation (F0567)2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)$8,824 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • 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
  • the CMS record shows $8,824 in federal fines (most recent 2024-11-04)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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.

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

Location & what’s nearby

Hospital
Urgent care / clinic
1765 Commercial St · (660) 438-6800 · Call to confirm hours
Pharmacy
1330 Commercial St · (660) 438-7331 · Call to confirm hours
Grocery
226 W Main St · (660) 223-0469 · Call to confirm hours
Park
Lay Park0.8 mi
Lay Ave · 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 4 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 1 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 rating1★
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 increased7.2%18.1%15.4%better
Long-stay residents who lose too much weight5.9%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%1.1%0.9%better
Long-stay residents with a urinary tract infection2.6%2.3%2.0%worse
Long-stay residents with depressive symptoms0.7%18.5%6.5%better than state — see note marked double-dagger below the table
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 injury3.9%4.1%3.3%worse
Long-stay residents whose ability to walk worsened5.6%17.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.8%25.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%90.9%95.3%typical
Long-stay residents with pressure ulcers4.9%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control15.1%17.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%23.5%17.1%better
Short-stay residents who newly got an antipsychotic medication2.4%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine98.5%63.5%79.4%better
Short-stay residents rehospitalized after admission22.4%26.0%22.6%typical
Short-stay residents with an outpatient ER visit12.7%13.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.822.111.67typical
Long-stay outpatient ER visits per 1,000 resident days3.182.331.80worse

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.

44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.0%U.S. median 51.5%
Got home and stayed home
12.7%U.S. median 10.7%
Went back to hospital
69.4%U.S. median 56.6%
Met the expected recovery
0.10U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 69.4% 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 36 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 0.10 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.0%CMS range 31.8–53.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.7%CMS range 8.3–17.410.7%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 discharge69.4%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 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 discharge63.9%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 identified87.2%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened8.5%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 hospitalization8.1%CMS range 4.2–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.22
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.01
Total nurse hours/ resident / day
0.21
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 90 beds and averages 73.3 residents a day — about 81% occupied, or roughly 17 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 3.01 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below 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 2.63 hrs/resident/day on weekends vs 3.17 on weekdays — 17% thinner on weekends. RN hours go from 0.22 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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 (2025-09-05)
13
at the previous standard inspection (2024-06-28)

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 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-29 · 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 keep two residents (Resident #1 and #2) free from physical abuse when Certified Nurse Aide (CNA) A forcefully transferred the residents from their beds to their wheelchairs. The facility census was 83.The administrator was notified on 10/29/25 of past Non-Compliance, which occurred on 10/22/25 when staff reported the allegation. Staff immediately suspended CNA A pending the results of the investigation; assessed the resident for physical and psychological harm; investigated; in-serviced staff on abuse, neglect, proper transfer techniques, and resident rights; and terminated the employee on 10/28/25. 1. Review of the facility's Abuse & Neglect Policy and Procedure, revised 04/16/24, showed the purpose of the policy is to ensure residents are free from abuse, neglect, misappropriation of resident's property, and exploitation. 2. Review of the facility's investigation, dated 10/22/25, showed the administrator documented CNA B and CNA C notified Licensed…

    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 · Past Non-Compliance
  • Actual harm · Gcited before2024-11-04 · 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 interview and record review, facility staff failed to properly assist one resident (Resident #1) up in bed, when Nursing Aide (NA) B wrapped his/her arms around the resident and moved the resident up in bed, which results in a injury. The facility census was 87. The administrator was notified on 11/1/24 of past Non-Compliance which occurred on 10/24/24. On 10/24/24 it was reported NA B wrapped his/her arms around Resident #1 on 10/23/24, and moved him/her up in bed which resulted in bruising to his/her left and right sides. Upon discovery on 10/24/24, staff started an investigation, inserviced staff on proper techniques for assisting residents while in bed, notified the physician and suspended the NA. Staff corrected the deficient practice on 10/24/24. 1. Review of the Facility's Moving a Resident with a Sheet/Pad Policy, dated 11/1/2001, showed staff are directed to grasp the lift sheet/pad with both hands and lift the resident toward the head of the bed. 2. Review of the facility's investigation, dated 10/24/24, showed Registered Nurse (RN) A reported to Licensed…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2025-09-05 · tag F0880 — failed to prevent and control infections — widespread
    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 develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. Facility staff failed to conduct an annual review of its Infection Prevention and Control Program (IPCP) and update their program, as necessary. Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents (Resident#13 and Resident #49) out of four sampled residents who required EBP, and failed to provide colostomy (an external bag attached to a surgically created stoma on the abdomen to collect stool after the colon is redirected due to a medical condition) care in a manner to prevent the spread of infection during care…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-05 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to refund resident funds within 30 days of discharge for 16 residents (Resident #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, and #97) out of 50 sampled residents. The facility census was 81.1. Review of the facility's policy titled Resident Trust, dated October 2022, showed the facility will convey refunds upon death or discharge of a resident within 30 days or within the timeframe prescribed by the state regulation.2. Review of the facility's aging report (report showing outstanding invoices and balances), dated 09/03/25, showed the following residents had money in the facility's operating account:Resident Amount Held in Operating Account#82 $235.00#83 $400.00#84 $2,040.00#85 $1,938.00#86 $529.01#87 $174.40#88 $5,704.00#89 $520.00#90 $240.00#91 $4,512.39#92 $634.46#93 $20.00#94 $240.00 #95 $140.00#96 $20.00#97 $231.00Total $17, 578.26 3. During an interview on 09/04/25 at 02:00 P.M., the Financial Specialist Assistant (FSA) said he/she oversees resident funds and petty cash. He/She said there…

    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 · D2025-09-05 · 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, interview and record review, facility staff failed to ensure one resident (Resident #3), received an accurate insulin dosage, failed to accurately transcribe a verbal insulin order in the electronic medication administration record (eMAR) for one resident (Resident #36), and failed to document an appropriate diagnosis for psychotropic medication use for one resident (Resident #101). The census was 81.1. Review of the facility's policy titled General Dose Preparation and Medication Preparation, dated 01/01/13, showed staff are instructed to confirm the MAR reflects the most recent medication order and follow manufacturer medication administration guidelines. Review of the facility's policy titled Subcutaneous Injection with Lantus SoloStar Pen, dated 2009, showed staff are instructed to perform a safety test by priming the insulin pen with two units of insulin to remove air bubbles and ensure the needle and pen are working properly.Review of the manufacturer's guidelines for Lantus insulin…

    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 · Dcited before2025-06-20 · 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

    Based on interviews and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical and sexual abuse when Certified Nursing Assistant (CNA) B pinched the resident's chest. The facility's census was 86. The administrator was notified on 06/20/25 of past Non-Compliance, which occurred on 06/12/25 when staff reported the allegation. Staff immediately suspended CNA B pending the results of the investigation, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 06/18/25. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed: -The facility strictly prohibits the abuse of residents; -This policy protects against abuse, neglect, exploitation and misappropriation of resident to include abuse by facility staff; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting…

    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 · Past Non-Compliance
  • Potential for harm · F2024-06-28 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 77. 1. Review of the facility's Dietary Manager / Food Services Director job description, reviewed 06/30/03, showed the individual must be a Certified Dietary Manager (CDM) in good standing or in training to satisfactorily complete the requirements to become a CDM. During an interview on 06/11/24 at 10:21 A.M., the Dietary Supervisor (DS) said he/she worked in the facility for 8 months and started as DS about two months ago. The DS said he/she had not started CDM classes yet and had never taken other food safety manager courses. The DS said he/she had food safety handling classes four or five years ago. The DS said he/she was not given a training completion timeline and had not received CDM course enrollment…

    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 · Fcited before2024-06-28 · 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 to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. Facility staff failed to maintain the kitchen ceiling in good repair to prevent the potential contamination of food. These failures have the potential to affect all residents. The facility census was 77. 1. Review of the facility's Handling Serviceware / Silverware policy, dated February 1, 2002, showed serviceware should be air dried and stored turned upside down, or covered. 2. Observation on 06/11/24 at 10:54 A.M., showed Dishwasher Q removed clean plate covers, plates, and cups from a rack on the drain board and placed the items on a service cart and a shelf above the drain board. Observation showed the items were stacked while still wet. Observation on 06/11/24 at 11:18 A.M., showed eight sheet pans stacked under the prep table while wet. Observation on 06/11/24 at 11:20 A.M., showed Dishwasher Q stacked service trays and plate warmers on a service cart. Observation showed the trays 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-28 · tag F0880 — failed to prevent and control infections — widespread
    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 prevent the spread of bacteria for three residents (Resident #21, #62, and #81) of four sampled residents when staff did not wash hands and change gloves during the provision of care, failed to prevent the spread of bacteria when staff did not wear the appropriate Personal Protective Equuipment (PPE) for one resident (Resident #21) of one sampled resident who had a wound and failed to post precaution signs on the doors of resident rooms to alert staff and visitors of the needed precautions for three residents (Resident #17, #82, and #244) of four sampled residents who required Enhanced Barrier Precautions (EBP). The facility census was 77. 1. Review of the facilty's Hand Hygiene policy, dated June 2020 directed staff to perform hand hygiene: -When hands are visibly soiled; -Before and after entering isoation precautions settings; -Before and after assisting a resident with personal care; -Upon and after coming in contact with a resident…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-28 · 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, interview and record review, facility staff failed to provided a safe, clean, comfortable, and homelike environment when facility staff did not repair damage in resident rooms and bathrooms. The facility census was 77. 1. Review of the facility's Federal Rights of Residents, dated 11/01/01, showed facility will provided a safe, clean, comfortable, and homelike environment. Review showed staff are directed to: -Clean beds and bath lines that are in good condition; -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 2. Observation on 06/11/24 at 10:15 A.M., showed occupied room [ROOM NUMBER]'s bathroom door with a large plastic scratch guard hung loose on one side with sharp edges and a heavily stained bathroom floor. Observation on 06/11/24 at 11:02 A.M., showed occupied room [ROOM NUMBER] doorframe with chipped paint, shower floor with brown stained tile, stained caulk around the toilet and privacy curtain partially torn. 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
  • Potential for harm · E2024-06-28 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete a thorough investigation when Licensed Practical Nurse (LPN) C reported he/she was accused by one resident (Resident #1) of making threats. The facility census was 84. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed staff were directed to: -The facility will investigate and document all incidents and accidents involving residents/guests, certain incidents and accidents must also be reported to the appropriate state agencies; -The facility will report all alleged instances of abuse -Notify the Administrator of an unusual situation in the facility, whether reportable or not, immediately; -The Administrator or designee will report to the State Agency and all other required agencies, per regulation; -All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours; -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 · E2024-06-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs for five (Resident #17, #20, #21, #82 and #244) of sixteen sampled residents. The facility census was 77. 1. Review of the facility's Nursing Assessment's policy, dated August 2018, showed: -The facility conducts, a comprehensive, standardized assessment of each resident's functional capacity necessary to develop a person centered care plan and to modify the care plan and care services based the resident's status and resident goals and preferences, future discharge; -Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident's condition; -The comprehensive person-centered care plan is established with input from the resident/resident representative and upon completion of a comprehensive Minimum Data Set (MDS) assessment, a federally mandated assessment tool completed…

    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
Show the remaining 17 citations
  • Potential for harm · E2024-06-28 · 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 appropriate personal hygiene, bathing, and incontinence care for seven (Resident #3, #20, #21, #47, #52, #54, and #81) out of 18 dependent sampled residents. The facility census was 77. 1. Review of the facility;s Hygiene and Grooming policy, dated 11/01/01, showed good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity Review showed staff care to include: A.M. Care to include: a) Offer bedpan, urinal or assistance to the bathroom; b) If the resident is incontinent of urine or stool, provide perineal care; c) Wash hands after returning utensils to proper place; d) Get a basin of warm water, and take to bedside for the resident to wash face and hands . Assist the resident as needed; e) Gather oral hygiene supplies, and take to bedside for the resident to brush teeth. Assist the resident as needed; f) Wash hand after returning utensils to proper place; g) Assist…

    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 · E2024-06-28 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 daily activities for all residents who reside on the secured unit. The facility census was 77. 1. Review of the facility's Delegation of Activity Program Duties policy, dated March 2008, showed: -The activities program should provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance to the extent practicable, each resident's physicial and mental status; and promote each resident's self-respect by providing, for example, activities that support self-expression and choice; -Activities should be designed to provide meaningful activity to each resident, consistent with their background and interests, every day. Review of the facility's Resident Daily Routines and Activities on the dementia unit policy, dated May 2002, showed: -Time not involved with activites of daily living care or formal activites can be meaningful for the resident by providing space that is safe, with objects for free exploration, such as scrapbooks, magazines, seed catalogs, memory boxes, etc.;…

    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 before2024-06-28 · 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 safely propel two residents (Resident #25, and #52) out of two residents in wheelchairs. Facility staff failed to ensure the residents' environment remained free of accident hazards when staff did not ensure access to a key for the employee bathroom on the secured unit was available and the door locked at all times to keep residents from entry. The facility census was 77. 1. Review of the facility's policies showed staff did not provide a policy for the use of wheelchairs. 2. Review of Resident #25's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/15/24, showed staff assessed resident as: -Severely cognitively impaired; -Required no assistance for locomotion short distances and partial assistance for long distances; -Wheelchair used as a mobility device. Observation on 06/12/24 at 07:14 A.M., showed Licensed Pratical Nurse (LPN) O propelled the resident in his/her wheelchair from the hallway to the dining…

    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 · E2024-06-28 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to obtain informed consent, complete entrapment assessments, and/or complete a side rail assessment the use of side rails and/or grab bars for nine (Resident #17, #20, #21 #32, #39, #41, #54, #82, and #244 ) of nine sampled residents . The facility census was 77. 1. Review of the facility's Proper Use of Side Rails Policy, dated 10/26/22, showed side rails should be addressed in the care plan and the resident and the resident representative should give informed consent to the use of the device, prior to its use. The facility did not provide entrapment or side rail assessments upon request. 2. Review of Resident #17's admission Minimum Data Set (MDS), a federally mandated assessment, dated 05/06/24, showed staff assessed the resident as: -Required partial/moderate assist in bed mobility; -Required partial/moderate assist in sit to stand; -Required partial/moderate assist in chair/bed to chair transfer; -Did not use side rails/restraints.…

    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 before2024-06-28 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to obtain a timely advanced directive for resident #238 who recieved CPR when he/she elected to be a DNR and failed to document residents' code status consistently as a Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for four residents (Resident #16, #42, #47 and #238) out of fifteen sampled residents. The facility census was 77. 1. Review of the facility's Advance Directives and Refusal of Treatment policy, dated [DATE], showed the resident has a right to formulate an advance directive for the management of his/her care. The resident shall have a copy of his/her advanced directive(s), if any, made a part of his/her medical record. Except in an emergency, prior to the start of any procedure or treatment, the resident shall receive the information necessary from his/her physician to give an informed consent. The information provided to the resident to obtain an informed consent shall include, but not…

    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 · D2024-06-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to report an allegation of abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe after being told the resident said a staff member tired to kill them. The facility census was 84. 1. Review of the facility's policy titled, Abuse, Neglect, Misappropriate of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, revised 10/24/22, showed certain incidents and accidents must also be reported to the appropriate state agencies. faclity staff are required to report all instances of abuse, neglect, exploitation, and misappropriation of resident/guest property, and suspicious injuries of unknown origin as required by state and federal law. Each employee has an obligation to immediately report any incident or allegation that constitute and instance of abuse, neglect, an injury of unknown origin, exploitation or misappropriation to the administrator, Director of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-28 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility administration failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes when facility staff failed to have an unlimited year history on the Criminal Background Checks (CBC) through the Missouri Highway Patrol for all new employees. The facility census was 77. 1. Review of the facility's Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation Policy, dated 10/24/22 showed the facility will search the appropriate registries and will conduct a background investigation to determine whether a finding of abuse, neglect, mistreatmnet, exploitation or misappropriation [NAME] been entered against a potential employe. This search will include all registries that the facility believes may have information. 2. Review of the contracted company for CBC checks letter, dated 6/12/24, showed the contracted company is to provide background screening services for…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-28 · 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 manually wash dishes in the three compartment sink while the dishwasher was under repair, to use the sanitizing solution according to manufacturer's instructions, and to allow dishes to air dry completely before use. The facility staff also failed to perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, to maintain a clean and sanitary environment in the kitchen, to store food in a manner to prevent contamination and outdated use, and to maintain the ice machine in a sanitary manner to prevent contamination and foodborne illness. The facility census was 77. 1. Review of the manufacturer's instructions for the facility's dishwasher showed: - Minimum wash water temperature 120 degrees (°) Fahrenheit (F); - Minimum rinse water temperature 120 ° F. Review of the facility's Dish Machine Sanitization policy, dated 08/10/28, showed: - Dish machines using chemicals for sanitation may be used if the temperature of the wash/rinse water meets manufacturer's recommendations…

    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 before2023-04-28 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility staff failed to document residents' code status consistently with Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) and/or enter orders for seven residents (Resident #18, #37, #51, #56, #68, #74, and #332). The facility census was 77. 1. Review of the facility's Advance Directive and Refusal of Treatment Policy, dated [DATE], showed the staff are directed as follows: -The resident has the right to refuse treatment, to refuse to participate in experimental research and to formulate an advance directive for the management of his/her care; -Upon the resident's admission to the Facility, the Social Services designee will obtain from the resident or the resident's family a copy of any existing Living will, Health Care Declaration or Health Care Directive, Durable Power of Attorney for Health Care, or any previously recorded express written or oral declarations; -This copy of the resident's written wishes should be placed…

    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 · E2023-04-28 · 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 and failed to ensure two Certified Medication Technician (CMT) medication carts and two nurse carts were locked at all times. The facility census was 77. 1. Review of the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 10/31/16, directed staff as follows: -Facility should ensure that medications and biologicals, including treatment items, are securely store in a locked cabinet/cart or locked medication room that is inaccessibly by residents and visitors; -Facility personnel should inspect nursing station storage areas for proper storage compliance on a regular scheduled basis. 2. Observation on 4/24/23 at 9:00 P.M., showed the CMT medication cart A contained the following loose pills: -One small round white pill stamped with HP 24; -Half of a small oval tan pill stamped with O; -Two oval orange pills stamped with W01; -One small oval white pill stamped with L612; -Half of a small blue pill stamped with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-28 · 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 interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and/or annual PPD tests were completed and documented as per the facility policy for five residents (#8, #15, #56, #61, and #74). The facility census was 77. 1. Review of the facility provided Tuberculosis Screening Policy, dated 12/1/2009, showed the policy directs staff as follows: -Upon admission, residents/guests should receive the PPD two-step screening. If screening was done by the transferring hospital, it must have occurred within 30 days prior to nursing home admission. The facility should obtain documentation of the results of X-Rays and PPD tests. 2. Review of Resident #8'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-28 · tag F0887 — isolated
    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 maintain and follow current guidance and procedures for immunizations of residents against Covid-19 for three (Residents #56, #71, and #74) sampled residents. The facility census was 77. 1. Review of the facility's Inoculation policy, dated 10/6/22, showed: -Records of flu, pneumonia, and Covid-19 vaccines should be maintained for easy retrieval; -Upon admission, the admitting nurse should interview the resident/guest and family/ responsible party, to determine the status of prior inoculations. Findings should be documented in the medical record and MDS; -Physician's orders for inoculations should be received, along with resident/guest/legal representative informed consent; -Document in the medical record, each dose of Covid-19 vaccine administered to resident or did not receive Covid-19 vaccine due to medical contraindications or refusal. 2. Review of Resident #56's medical record showed: -Most recent admission date of 3/17/22; -The record did not contain documentation the resident received, refused, or was offered 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-04-28 · tag F0575 — widespread
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, facility staff failed to post the required telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to residents and visitors. The census was 77. 1. Review of the facility's Nursing Management Manual, Resident/Guest Rights, October 24, 2022, showed: IV. Identification of Resident/Guest Incident and Accidents; C. The facility will place notices throughout the facility to inform visitors of how they can make complaints concerning a resident /guest(s) treatment. Observations from 4/24/23 at 8:00 P.M. to 4/28/23 at 3:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents, visitors or staff. During an interview on 4/27/23 at 10:30 A.M., License Practical Nurse (LPN) A said the abuse and neglect hotline should be posted on the cork board by the nurse's station. He/She said if it is not on the cork board that…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-04-28 · tag F0623 — widespread
    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 interview and record review, facility staff failed to ensure staff provided a written notice of discharge/transfer to the resident or the resident's representatives regarding transfers to the hospital for three out of four sampled residents (Resident #18, #36, and #74). The facility census was 77. 1. Review of the facility's Discharge, Transfer, and Therapeutic Leaves Policy, effective 6/26/19, showed: Emergency Transfers/Discharges: Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident/guest, or other residents/guests. Emergency transfer procedures should include the following: -A copy of resident/guest bed hold and admission policies / transfer to hospital notice should be provided upon transfer by the assigned nurse to resident and/or representative of resident. 2. Review of Resident #18's medical record showed the following: -Transferred to the hospital on 2/21/23; -Returned to the facility on 2/23/23; -Staff did not document they notified the resident and or the resident's representative of the transfer 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-04-28 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for three sampled residents (Resident #18, #36, and #74). The facility census was 77. 1. Review of the facility's Discharge, Transfer, and Therapeutic Leaves Policy, effective 6/26/19, showed: Emergency Transfers/Discharges: Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident/guest, or other residents/guests. Emergency transfer procedures should include the following: -A copy of resident/guest bed hold and admission policies / transfer to hospital notice should be provided upon transfer by the assigned nurse to resident and/or representative of resident. 2. Review of Resident #18's medical record showed the following: -Transferred to the hospital on 2/21/23; -Returned to the facility on 2/23/23; -Staff did not document they notified the resident and or the resident's representative of bed hold policy in writing. 3.…

    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 · C2023-04-28 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    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, interviews, and record review, the facility staff failed to ensure staff served food to the residents that was palatable, attractive, and at a safe and appetizing temperature. The facility staff also failed to provide residents the portion size instructed by the recipe. The census was 77. 1. Review of the facility's policies and procedures showed the facility did not have a policy in regards to food temperatures. Observation on 4/25/23 at 12:15 P.M., showed staff delivered a covered hall tray to Resident #21, on the 200 hall from the kitchen on an open cart. The temperature of the cheese steak was 90 (°) Fahrenheit (F) at the time of delivery. During an interview on 4/25/23 at 12:20 P.M., the resident said often times the food is not hot when it gets to his/her room. He/She said the food was only slightly warm today. He/She said you cannot expect much from the facility's food. During an interview on 4/24/23 9:31 P.M., the resident said the food is cold, and it makes the food not taste good. Observation on 4/25/23 at 12:20 P.M., showed staff delivered a covered…

    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 · C2023-04-28 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, facility staff failed to implement policies and procedures to ensure all staff were fully vaccinated for Coronavirus 2019 (a highly contagious virus that causes serious illness or death), (COVID-19) or had been granted a qualifying exemption. Two employees (Licensed Practical Nurse (LPN) A and LPN K) were granted a medical exemption with a clinical reason not approved by the Center for Disease Control (CDC), one employee (Certified Nursing Assistant (CNA) J) was partially vaccinated, and eleven employees (Nursing Assistant (NA) L, Housekeeper M, NA N, CNA O, NA P, NA Q, NA R, NA S, NA T, NA U, and NA V) had pending exemptions. The facility had 21% of employees not fully vaccinated or without a granted qualifying exemption. The facility census was 77. 1. Review of the facility's Flu/Pneumovax Permission and Education Implementation Protocol Policy, effective 10/6/22, showed: -All eligible staff must have received either two doses of Pfizer or Moderna or one dose of Johnson & Johnson by January 4, 2022, even if they have not yet completed 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.

    Infection Control 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

$8,824 in federal fines across 1 penalty.

  • $8,824 — penalty dated 2024-11-04

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ASPIRE SENIOR LIVING — 16 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 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 2 of 51.4+0.6 vs chain
Quality measures 3 of 52.5+0.5 vs chain
The other 15 homes this chain runs (chain average 1.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
NORTHPORT HEALTH SERVICES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST75%since 09/29/1997
ESTES, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER25%since 09/29/1997
JAMES N ESTES JR FAMILY DYNASTY TR NO 1Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/31/2020
JAMES NORMAN ESTES JR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/29/1997
JENNIFER E AGEE FAMILY DYNASTY TR NO 1Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/31/2020
JENNIFER LEE ESTES TR 031093Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/29/1997
REGIONS BANKOrganization5% OR GREATER SECURITY INTERESTsince 08/27/2013
GOULD, CASANDRAIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 06/19/2023
ALDANA, MICHELLEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 12/23/2019
RASCO, LYNNIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2022
VANBIBBER, KARLIIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 09/25/2023
LONG, PHILLIPIndividualCORPORATE OFFICERsince 10/01/2019

CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$6.5M
Net patient revenuemost recent cost report
-19.6%
Operating marginrevenue minus expenses
$763K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 6%Other / private 25%

This home reported $763K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$265per resident / day
operating cost
$8,065per month
≈ monthly operating cost
$222per 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 265566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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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