Brooke Haven Healthcare
1410 North Kentucky Avenue, West Plains, MO 65775 · Non profit - Corporation · 120 certified beds · (417) 256-7975 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2023
- it has citations for mishandling residents’ money or property (F0569, F0570)
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,033 in federal fines (most recent 2024-12-06)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.8% | 18.1% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.7% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.2% | 18.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.3% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.6% | 17.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.4% | 25.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.3% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 18.5% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.7% | 23.5% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 32.3% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.9% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.4% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.11 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.73 | 2.33 | 1.80 | typical |
‡ 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.
49.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.5% 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 44 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 38.9–61.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.5–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.5–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.81 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 61.1 residents a day — about 51% occupied, or roughly 59 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.55 hrs/resident/day on weekends vs 4.02 on weekdays — 12% thinner on weekends. RN hours go from 0.43 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2024-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a safe environment per the resident's assessed level of need, when Resident #21 received a second degree (a burn that damages the epidermis and dermis, the two layers of skin) burn from the spilled coffee in his/her lap after a Certified Nursing Assistant (CNA) handed the resident hot coffee in a coffee cup without a lid for one sampled resident. The census was 69. The facility did not provide a policy regarding accidents/incidents. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/19/24, showed: - Diagnoses of non-traumatic brain injury (brain injury that occurs due to internal factors, rather than an external force to the head), dementia ( general term for a group of neurological conditions that cause a decline in mental abilities that affects daily life), and anxiety ( a feeling of fear, dread, and uneasiness that can be a normal reaction to stress); - Cognition severely impaired; - No speech and 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.
- Potential for harm · D2026-03-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to assure staff treated five sampled residents (Residents #1, #11, #30, #31, and #39) in a manner that maintained their dignity during mealtimes by standing during meals, assisting multiple residents at a time, and meals being served without assistance available. The facility census was 57.Review of the facility policy titled, Resident Rights, revised December 2016, showed:- Employees shall treat all residents with kindness, respect, and dignity;- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be supported by the facility in exercising his/her rights. The facility did not provide a policy on dining assistance. 1. Observation on 02/24/26 at 11:40 A.M. to 12:15 P.M., showed:- Certified Nursing Assistant (CNA) D stood to the front and to the right of Resident #58 while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-03 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for three residents (Residents #69, #71, and #72) out of three sampled residents and failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident (Resident #70) out of one sampled resident. The facility census was 57.Review of the facility's policy titled, Resident Trust Fund, undated, showed:- When a resident leaves the facility with no plans to return, their Resident Trust Fund (RTF) account must be closed out;- If a resident moves to another nursing facility, it is the responsibility of the office staff to make arrangements to transfer any balance to that resident at the new facility, the office manager will first make sure that no funds are due to the facility for any reason, If there are outstanding balances with the facility, those funds remaining will be considered for use to cover such balances;- If the facility is representative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-03 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a preadmission screening and resident review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder and to determine the level of care needed) for one resident (Resident #8) out of two sampled residents and one resident (Resident #52) outside the sample. The facility census was 57.The facility failed to provide a policy regarding the PASRR. 1. Review of Resident #8's medical record showed:- admitted on [DATE];- Diagnoses of stroke, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), aphasia (loss of ability to understand or express speech caused by brain damage), depression (a serious medical illness that negatively affects how you feel, think, and act), anxiety (persistent worry and fear about everyday situations), cognitive communication deficit (difficulty in communication), mild cognitive impairment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to document the type, the stage, the measurements, and the characteristics of the facility acquired pressure ulcer (areas of localized damage to the skin and/or underlying soft tissue usually over a bony prominence, generally the result of pressure, shear, and/or friction) and also failed to notify and obtain a physician order for one resident (Resident #11) out of one sampled resident with a pressure ulcer. This resulted in Resident #11's stage 1 (intact skin with non-blanchable (discoloration of the skin that does not turn white when pressed) redness of a localized area usually over a bony prominence) pressure ulcer progressing to an open wound. The facility census was 57. Review of the facility's policy titled, Pressure Injury Risk Assessment, dated March 2020, showed:- The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs);- Risk factors that increase a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure proper storage of nasal cannulas (plastic tubing placed in the nostrils to provide supplemental oxygen) when not in use for two residents (Residents #4 and #38) and failed to follow oxygen orders for two residents (Residents #38 and #52) out of four sampled residents. The facility census was 57.Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed:- Verify there is a physician's order for this procedure;- Review the physician's orders or facility protocol for oxygen administration;- Assemble the equipment and supplies as needed;- Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter);- Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered;- Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened, be sure there is water in the humidifying jar and that the water level is high enough that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-03 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
:Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 25 opportunities with two errors made, resulting in an error rate of 8% for two residents (Residents #13 and #54) out of seven sampled residents. The facility's census was 57.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so;- Medications are in accordance with prescriber orders, including any required time frame;- Insulin pens containing multiple doses of insulin are for single resident use only;- Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident;- Each nurse's station has manufacturer's instructions or user's manuals related to any medication administration devices kept with the devices or at the nurses'…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) and follow appropriate infection control practices with hand hygiene and glove changes when staff performed wound care for three residents (Residents #2, #20, and #58) out of four sampled residents, and during incontinent care for three residents (Residents #11, #31, and #58) out of four sampled residents. The facility also failed to correctly screen three residents (Residents #20, #51, and #68) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents as required by state regulation 19 CSR 20-20.100. The facility census was 57. Review of the facility's policy titled, Wound Care, dated October 2010, showed:- Wipe nozzles, foil packed, bottle top, with alcohol before opening;- Use disposable cloth to establish clean field on resident's overbed table;- Wash and dry hands thoroughly;- Wash and dry hands…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the kitchen. 1. Observation on 12/03/24 at 9:34 A.M., and 12/05/24 at 11:38 P.M., of the kitchen showed: - No cleaning logs; - Two unlabeled white plastic food bins with clear unlabeled lids near the gas range with white sugar and brown sugar; - A metal backsplash behind the gas range with a 2 foot (ft.) diameter (dia.) area with dark brown carbon build-up; - The commercial style can opener with an oily film on the base and blade; - One 3 ft. by 4 ft. diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers outside the water heater closet door; - The floor below the reach-in freezer, the reach-in refrigerator, gas range, deep fryer, mixer, and food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0570 — isolatedAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of the residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from October 2023 to September 2024. The facility census was 69. The facility did not provide a policy for the surety bond. 1. Review of the residents' personal funds account on 12/05/24, for the last twelve consecutive months from October 2023 to September 2024, showed: - The facility's current approved bond amount equaled $100,000.00; - The average monthly balance for the residents' personal funds equaled $68,621.10; - An average monthly balance of $68,621.10 required a bond of at least $103,500. During an interview on 12/05/24 at 11:07 A.M., the Business Office Manager (BOM) said the surety bond should be one and one-half times the amount on the residents' trust balance. During an interview on 12/05/24 at 11:20 A.M., the Administrator said the surety bond amount should be one and one-half times the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #118) out of six sampled residents when the facility failed to administer the correct amount of insulin (a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells for energy). The facility also failed to follow Registered Dietician (RD) recommendations for one resident (Residents #22) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in a safe and timely manner and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. The facility did not provide a policy regarding RD recommendations. 1. Review of Resident #22's medical record showed: - Diagnosis of cerebral palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture); No documentation regarding the RD's recommendation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-12-06 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive discharge summary for two residents (Residents #58 and #66) out of two discharged residents. The facility's census was 69. The facility did not provide a policy regarding a discharge summary or recapitulation. 1. Review of Resident #58's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a recapitulation or completed discharge summary. 2. Review of Resident #66's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a recapitulation or completed discharge summary. During an interview on 12/07/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said the discharging nurse was responsible for completing the discharge summary. The discharge summary and the recapitulation should be completed prior to the discharge of a resident.
- Potential for harm · D2024-12-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a urinary catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was kept off the floor for one resident (Resident #31) out of two sampled residents. The facility census was 69. Review of the facility policy titled, Catheter Care, Urinary, Revised August 2022, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #31's Physician Order Sheet (POS), dated December 2024, showed: - An order for urinary catheter care every shift for urinary retention (an inability to empty the bladder of urine), dated 11/26/24; - An order for a 16 French (FR - size of catheter) catheter with 10 cubic centimeter (cc) bulb one time a day every one month starting on the 15th for 28 days, dated 11/26/24; - An order for a 16 FR catheter with 10 cc bulb for occlusion or leakage as needed, dated 11/26/24; - An order to empty the catheter drainage bag and chart the output every shift, dated 11/27/24. Observation of the resident showed: - On 12/04/24 at 9:33…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy for two residents (Residents #39 and #62) out of two sampled residents, and failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #39) out of one sampled resident. The facility census was 69. The facility did not provide an oxygen policy. Review of the facility's policy titled, Tracheostomy Care, revised August 2023, showed: - The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas; - Aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes; during tracheostomy tube changes, either reusable or disposable; - Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures; - Remove old dressings. Pull soiled glove over dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #31) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts to the event) out of one sampled resident. The facility's census was 69. The facility did not provide a PTSD policy. 1. Review of Resident #31's medical record showed: - admission date of 08/12/24; - Diagnoses of PTSD, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety disorder (persistent worry and fear about everyday situations); - Trauma Informed Care Assessment, dated 11/06/24, showed resident triggered for PTSD. Review of the resident's Physician Order sheet (POS), dated December 2024, showed: - An order for alprazolam (an antianxiety medication) 0.25 milligrams (mg) by mouth every 8 hours as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors for three out of four days. The facility census was 69. The facility did not provide a policy regarding posting of nurse staffing. Observation on 12/04/24 at 9:30 A.M., 12/05/24 at 11:00 A.M., and 12/06/24 at 12:00 P.M., of the facility's Staff Posting Sheet, located on a bulletin board beside the nurse's station showed: -The Staff Posting Sheet, dated 12/02/24; -The facility did not post the required daily nurse staffing information for 12/04/24, 12/05/24, and 12/06/24. During an interview on 12/06/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said nurse staffing should be posted on the Nurse Staffing board daily.
- Potential for harm · D2024-12-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the narcotic reconciliations (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) were accurate when on-coming and off-going staff failed to document narcotic medications as they were administered for two residents (Residents #21 and #46) which resulted in the inaccuracy of the narcotic counts. The facility census was 69. The facility did not provide a policy for the narcotic count. 1. Review of the 100/200 Certified Medication Technician's (CMT's) cart Controlled Drug Receipt-Record Disposition form on 12/05/24 at 9:45 A.M., showed: - A count of 22 tablets for Resident #21's hydrocodone (a narcotic pain medication) 5/325 milligram (mg) by mouth two times a day for pain, dated 06/13/24; - A count of seven tablets for Resident #46's eszopichlone (a hypnotic medication used to help a person sleep) 3 mg by mouth at night, dated 04/23/24. Observation on 12/05/24 at 9:45 A.M., of the 100/200 CMT's medication cart showed: - A count of 20 tablets for Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for one resident (Resident 29), failed to attempt a gradual dose reduction (GDR) for one resident (Resident #7), and failed to ensure an appropriate diagnosis for the use of a psychotropic medication for two residents (Residents #31 and #43) out of nine sampled residents. The facility census was 69. Review of the facility policy titled, Tapering Medications and GDR, revised April 2007, showed: - Within the first year after a resident is admitted on an antipsychotic (a class of medications used to treat psychosis) medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between attempts), unless clinically contraindicated; - After the first year, the facility shall attempt a GDR at least annually, unless…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner when opened insulin was found undated in the medication cart, failed to ensure the medication cart was locked while unattended, and the facility failed to ensure resident safety by leaving medication in one resident's (Resident #31) room, unattended out of one sampled resident. This had the potential to affect all residents. The facility census was 69. Review of the facility policy titled, Storage of Medications, dated April 2007, showed: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff shall be responsible for maintaining medication storage; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; - Compartments containing drugs shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the facility policy titled, Administering Medications,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the dumpster. 1. Observations on 12/03/24 at 10:17 A.M., 12/05/24 at 11:33 A.M., and 12/06/24 at 8:53 P.M., of the outside trash dumpster located near the kitchen entrance showed one 6-yard (yd.) dumpster partially filled with two plastic lids completely opened. During an interview on 12/05/24 at 2:10 P.M., the Administrator said the dumpster should be closed when it was unattended and not being filled by the facility staff. During an interview on 12/06/24 at 8:56 A.M., the Assistant Maintenance Director said the trash dumpster should remain closed when it was not being filled. Most of the facility staff were expected to throw trash in the dumpster. The staff had been trained to close the lid on the dumpster but it didn't always get closed.
- Potential for harm · Dcited before2024-12-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes during wound care for two residents (Residents #21 and #36) out of three sampled residents, incontinence care for two residents (Residents #9 and #60) out of five sampled residents, and Foley catheter (a flexible tube inserted into the bladder to drain urine through the urethra) care for one resident (Resident #32) out of one sampled resident. Additionally, the facility failed to follow Enhanced Barrier Precautions (EBP), including wearing of a gown, during high contact patient care activities to prevent the spread of multi-resistant organisms for one resident (Resident #32) out of four sampled residents. The facility failed to ensure standard infection control practices were maintained for one resident (Resident #21) out of three sampled residents when staff placed a dressing on a towel then applied it directly to the burn wound bed. The facility failed to ensure standard infection control practices were maintained for three residents (Residents #62, #118, and #119) out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-06 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 69. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotic will be prescribed and administered to the residents under the guidance and the facility's Antibiotic Stewardship Program; - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. Review on 12/06/24 at 9:45 A.M., of the Antibiotic Stewardship Program showed: - No documentation of the antibiotic stewardship tracking completed. Review of the October 2024 Quality Assurance Performance Improvement (QAPI) meeting minutes for Infection Control showed: - The total number of infection from previous month verses this month; - The number of infections per body system; - Number of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow professional standards of practice for one resident (Resident #1) of three sampled residents. The facility failed to follow physician's orders and did not attain treatment orders for a wound in a timely manner. The facility census was 69. Review of the facility's policy titled admission Assessment and Follow Up: Role of the Nurse, dated September 2012, showed: - The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including Minimum Data Set (MDS); - Conduct admission assessment including a summary of the individual's recent hospitalization, acute illnesses and overall status prior to admission; - Assessment to include list of active medical diagnosis and patient problems, especially those most related to reason for admission to the facility and those that are affecting function, behavior, cognition,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to keep one of two facility ice machines clean and sanitary. The failure created the potential for contamination of the ice used for ice water and ice chips for 65 of 66 residents in the facility. 1. Observation on 07/03/23, at 3:35 P.M., of the ice machine utilized to provide ice for the facility residents, showed the following: -The inside of the blue ice scoop receptacle was dirty with dark black matter at the bottom where the scoop was placed; -The outside of the white ice scoop was black on one side; -Corrosion around the base of the condenser located on the top of the ice machine. Particles from the corrosion could fall into the ice when the lid was opened. During an interview on 07/03/23, at 3:49 P.M., [NAME] 8, the Director of Nursing (DON), and a Maintenance Staff (MS) all confirmed the above observation. [NAME] 8 denied that the kitchen staff were responsible to clean the identified ice machine. [NAME] 8 said he/she believed the nursing staff were to clean it. The MS said he/she did not know when the ice machine,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, record review, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for for all residents when the facility failed to maintain clean floors and failed to maintain one resident room, without holes in the walls, where two residents (Resident #6 and #10) resided. 1. Review of Resident #6's Clinical Census, found in the electronic medical record (EMR), under the Clinical tab showed the following: -admission date of 09/25/16; -Diagnoses included bilateral (both sides) hearing loss, legal blindness, adult osteochondrosis of spine (pathologic degenerative process involving the intervertebral disc and the respective vertebral body endplates), and major depressive disorder. Review of Resident #6's annual Minimum Data Set Assessment (MDS - a federally mandated assessment tool complete by facility staff), with an assessment reference date (ARD) of 05/03/23, showed the resident had a score of 99 on the Brief Interview for Mental Status (BIMS),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-06 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review,the facility failed to follow related Centers for Disease Control and Prevention (CDC) guidelines for pneumococcal vaccinations for four residents (Resident #26, #33, #35, and #49) of five sampled residents reviewed for influenza/pneumococcal vaccinations. Review of document provided by the facility titled Pneumococcal Vaccination Update/CDC/Advisory Committee on Immunization Practices (ACIP) Guidelines for Older Adults in Long-Term Care Facilities showed the following: -For resident of age greater of equal to [AGE] years of age, giving a dose of the Pneumococcal Conjugate Vaccine ( PCV) 13 was based on clinical decision-making; -For Pneumococcal Polysaccharide Vaccine (PPSV23), it would be one dose; -If PCV13 has been given, then give one year after PCV13. Review of the facility's policy titled Pneumococcal Vaccine, revised 10/19, showed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, 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.
- Potential for harm · D2023-07-06 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to protect two residents' (Resident #17 and #52) right to be free from physical abuse when staff failed sufficiently monitor one resident (Resident #169) after the resident hit, or was alleged to have hit, a resident. Review of the facility's policy titled, Resident-to-Resident Altercations, revised September 2022 showed the following: -Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents; -Behaviors that may provoke a reaction by residents or others include physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; -If two residents are involved in an altercation, staff separate the residents, and institute measures to calm the situation. 1. Review of Resident #169's admission Record, undated, located under the Profile tab, showed the following: -admission date of 04/03/23; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to assess any potential cause and failed to care plan regarding an itchy scalp and possible scalp condition for one out of one resident (Resident # 21). 1. Review of Resident #21's Clinical tab, located in the electronic medical record (EMR), showed the following: -admission date of 06/21/22; -Diagnoses included Alzheimer's disease and anxiety disorder. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), located under the MDS tab, with an Assessment Reference Date (ARD) of 06/16/23, showed a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating the resident was severely cognitively impaired. Review of the resident's Care Plan, located under the Care Plan Detail, tab, with a a revision date of 06/29/23, showed the following: -Care plan identified a focus concern of risk for impaired skin integrity related to impaired bed mobility and incontinence. Observations 07/03/23 showed the following: -At 11:50 A.M., 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,033 in federal fines across 1 penalty.
- $10,033 — penalty dated 2024-12-06
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WILLOW HEALTH CARE INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 11/01/2003 |
| ALTER, SHIRLEY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 07/02/2019 |
| CLARK, SHEILA | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2010 |
| MILLER, SHERRY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 09/01/2009 |
| WILLIAMSON, JACKIE | Individual | W-2 MANAGING EMPLOYEE | — | since 10/14/2009 |
| AUALA, ELQUIN | Individual | CORPORATE DIRECTOR | — | since 05/11/2004 |
| OGDEN, JAMES | Individual | CORPORATE DIRECTOR | — | since 05/11/2004 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $348K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265400. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-03, 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.