The Vardell Report.Fieser Nursing Center

Across 4 inspections from December 2021 to September 2025, state surveyors documented 56 findings at Fieser Nursing Center; 56 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

4

2021–2025, standard and complaint

Findings

56

Deficiencies cited by state inspectors

Corrected

56

Of 56 findings, with a recorded correction date

Penalties

1

1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Sep 302025

   Standard health inspection

   14 findings

   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Nov 13, 2025
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level ENo actual harm, potential for moreCorrected Nov 13, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Nov 13, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 13, 2025
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Nov 13, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 13, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Nov 13, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Oct 172024

   Complaint investigation

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 30, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 4, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Feb 202024

   Standard health inspection

   19 findings

   The same visit included a complaint investigation.

   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Apr 6, 2024
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 6, 2024
   • F637Assess the resident when there is a significant change in conditionLevel ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.Level ENo actual harm, potential for moreCorrected Apr 15, 2024
   • F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level ENo actual harm, potential for moreCorrected Apr 6, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 6, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 6, 2024
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 6, 2024

   Enforcement Action

   Denial of payment imposed February 20, 2024. Status: Closed, April 15, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 20, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Dec 202021

   Standard health inspection

   21 findings

   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level FNo actual harm, potential for moreCorrected Feb 3, 2022
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level FNo actual harm, potential for moreCorrected Feb 3, 2022
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level FNo actual harm, potential for moreCorrected Feb 3, 2022
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Feb 3, 2022
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Feb 3, 2022
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 3, 2022
   • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F700Try 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.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Level DNo actual harm, potential for moreCorrected Feb 3, 2022
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Feb 3, 2022
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Feb 3, 2022
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level CPotential for minimal harmCorrected Feb 3, 2022

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in December 2021, February 2024 and September 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F656 across all 4 inspections, oldest to newest
2. 2

   Pressure Injury Care, Cited in Three Inspections

   Inspectors cited F686 in February 2024, October 2024 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F686 across all 4 inspections, oldest to newest
3. 3

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in December 2021, February 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F880 across all 4 inspections, oldest to newest
4. 4

   Citation F577, Cited in Two Inspections

   Inspectors cited F577 in December 2021 and September 2025. The agency describes it this way: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F577 across all 4 inspections, oldest to newest
5. 5

   Citation F636, Cited in Two Inspections

   Inspectors cited F636 in December 2021 and February 2024. The agency describes it this way: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F636 across all 4 inspections, oldest to newest
6. 6

   Citation F638, Cited in Two Inspections

   Inspectors cited F638 in December 2021 and February 2024. The agency describes it this way: Assure that each resident’s assessment is updated at least once every 3 months. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F638 across all 4 inspections, oldest to newest
7. 7

   Citation F640, Cited in Two Inspections

   Inspectors cited F640 in December 2021 and February 2024. The agency describes it this way: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F640 across all 4 inspections, oldest to newest
8. 8

   Accident Hazards and Supervision, Cited in Two Inspections

   Inspectors cited F689 in December 2021 and February 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F689 across all 4 inspections, oldest to newest
9. 9

   Post nurse staffing information every day, Cited in Two Inspections

   Inspectors cited F732 in December 2021 and September 2025. The agency describes it this way: Post nurse staffing information every day. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   21242425F732 across all 4 inspections, oldest to newest
10. 10

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in February 2024 and September 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    21242425F761 across all 4 inspections, oldest to newest
11. 11

    Citation F838, Cited in Two Inspections

    Inspectors cited F838 in December 2021 and September 2025. The agency describes it this way: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    21242425F838 across all 4 inspections, oldest to newest
12. 12

    Citation F851, Cited in Two Inspections

    Inspectors cited F851 in February 2024 and September 2025. The agency describes it this way: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    21242425F851 across all 4 inspections, oldest to newest
13. 13

    Citation F868, Cited in Two Inspections

    Inspectors cited F868 in December 2021 and September 2025. The agency describes it this way: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    21242425F868 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in three inspections, most seriously at level E.

2. 02

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in three inspections, most seriously at level D.

3. 03

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

4. 04

   What changed after F577 was cited, and how do you check it now?

   Citation F577: cited in two inspections, most seriously at level D.

5. 05

   What changed after F636 was cited, and how do you check it now?

   Citation F636: cited in two inspections, most seriously at level F.

6. 06

   What changed after F638 was cited, and how do you check it now?

   Citation F638: cited in two inspections, most seriously at level F.

7. 07

   What changed after F640 was cited, and how do you check it now?

   Citation F640: cited in two inspections, most seriously at level F.

8. 08

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in two inspections, most seriously at level E.

9. 09

   What changed after F732 was cited, and how do you check it now?

   Post nurse staffing information every day: cited in two inspections, most seriously at level C.

10. 10

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

11. 11

    What changed after F838 was cited, and how do you check it now?

    Citation F838: cited in two inspections, most seriously at level E.

12. 12

    What changed after F851 was cited, and how do you check it now?

    Citation F851: cited in two inspections, most seriously at level F.

13. 13

    What changed after F868 was cited, and how do you check it now?

    Citation F868: cited in two inspections, most seriously at level F.

14. 14

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

15. 15

    What led to the 2024 denial of payment, and what would you want a family to know about it?

    Denial of payment was imposed February 20, 2024; it ended April 15, 2024.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Missouri state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Missouri state survey agency

  Inspection Dec 20, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Missouri state survey agency

  Inspection Feb 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Missouri state survey agency

  Inspection Oct 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Missouri state survey agency

  Inspection Sep 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 26A490

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.