The Vardell Report.Springfield Skilled Care Center

Across 18 inspections from November 2019 to July 2026, state surveyors documented 102 findings at Springfield Skilled Care Center; 102 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

18

2019–2026, complaint and standard

Findings

102

Deficiencies cited by state inspectors

Corrected

102

Of 102 findings, with a recorded correction date

Penalties

3

2 fines; payment not published, 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. Jul 82026

   Complaint investigation

   1 finding

   • F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.Level DNo actual harm, potential for moreCorrected Jul 31, 2026

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

2. Jun 122026

   Complaint investigation

   6 findings

   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Jul 27, 2026
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jul 27, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Jul 27, 2026
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Jul 27, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 27, 2026
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Jul 27, 2026

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

3. Jan 272026

   Complaint investigation

   1 finding

   • 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 Feb 24, 2026

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

4. Jan 132026

   Complaint investigation

   6 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Feb 24, 2026
   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Feb 24, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Feb 24, 2026
   • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Feb 24, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 24, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Feb 24, 2026

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

5. Apr 102025

   Complaint investigation

   1 finding

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 20, 2025

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

6. Feb 132025

   Standard health inspection

   19 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Mar 27, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Mar 27, 2025
   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Mar 27, 2025
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Mar 27, 2025
   • 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 ENo actual harm, potential for moreCorrected May 20, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 20, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • 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 Mar 27, 2025
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 20, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Mar 27, 2025
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Mar 27, 2025
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 27, 2025

   Enforcement Action

   Civil money penalty, $105,521 imposed February 13, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 13, 2025, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed February 13, 2025. Status: Closed, May 20, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 13, 2025, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $54,304 imposed January 13, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 13, 2025, the nearest before the penalty date.

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

7. Nov 202024

   Complaint investigation

   1 finding

   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Dec 27, 2024

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

8. Oct 72024

   Complaint investigation

   3 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Oct 11, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Oct 11, 2024

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

9. Sep 122024

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 11, 2024

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

10. Aug 302024

    Complaint investigation

    5 findings

    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • 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 Oct 11, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 11, 2024

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

11. Jul 292024

    Complaint investigation

    6 findings

    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Aug 22, 2024
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • 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 Oct 11, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 11, 2024

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

12. Jul 122024

    Complaint investigation

    6 findings

    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 11, 2024
    • 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 Oct 11, 2024
    • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 22, 2024
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 11, 2024

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

13. Jan 312024

    Complaint investigation

    2 findings

    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 21, 2024
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Feb 21, 2024

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

14. Jan 242024

    Complaint investigation

    1 finding

    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Feb 21, 2024

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

15. Dec 62023

    Complaint investigation

    1 finding

    • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Jan 9, 2024

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

16. Nov 212023

    Complaint investigation

    1 finding

    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level ENo actual harm, potential for moreCorrected Nov 10, 2023

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

17. Feb 32023

    Standard health inspection

    22 findings

    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Mar 15, 2023
    • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F584Honor 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.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • 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 Mar 15, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 15, 2023
    • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Mar 15, 2023
    • F575Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.Level BPotential for minimal harmCorrected Mar 15, 2023

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

18. Nov 262019

    Standard health inspection

    19 findings

    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Jan 10, 2020
    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Jan 10, 2020
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • 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 Jan 10, 2020
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jan 10, 2020
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • 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 Jan 10, 2020
    • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jan 10, 2020
    • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 10, 2020

    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

   Infection Control, Cited in Seven Inspections

   Inspectors cited F880 in November 2019, February 2023, January 2024, July 2024, July 2024, August 2024 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.

   192323232424242424242424252526262626F880 across all 18 inspections, oldest to newest
2. 2

   A Clean, Homelike Setting, Cited in Six Inspections

   Inspectors cited F584 in February 2023, January 2024, July 2024, July 2024, August 2024 and June 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.

   192323232424242424242424252526262626F584 across all 18 inspections, oldest to newest
3. 3

   Help With Daily Living, Cited in Five Inspections

   Inspectors cited F677 in February 2023, July 2024, July 2024, August 2024 and February 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

   192323232424242424242424252526262626F677 across all 18 inspections, oldest to newest
4. 4

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in November 2019, July 2024, July 2024, August 2024 and February 2025. 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.

   192323232424242424242424252526262626F689 across all 18 inspections, oldest to newest
5. 5

   Pharmacy Services, Cited in Five Inspections

   Inspectors cited F755 in November 2019, July 2024, February 2025, April 2025 and January 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. 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.

   192323232424242424242424252526262626F755 across all 18 inspections, oldest to newest
6. 6

   Significant Medication Errors, Cited in Five Inspections

   Inspectors cited F760 in February 2023, July 2024, February 2025, January 2026 and June 2026. This citation covers whether residents are free from significant medication errors. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192323232424242424242424252526262626F760 across all 18 inspections, oldest to newest
7. 7

   Care Plan Timing and Review, Cited in Four Inspections

   Inspectors cited F657 in February 2023, July 2024, July 2024 and August 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. 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.

   192323232424242424242424252526262626F657 across all 18 inspections, oldest to newest
8. 8

   Medication Error Rate, Cited in Four Inspections

   Inspectors cited F759 in November 2019, February 2023, January 2026 and June 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.

   192323232424242424242424252526262626F759 across all 18 inspections, oldest to newest
9. 9

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in November 2019, February 2023 and September 2024. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. 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.

   192323232424242424242424252526262626F609 across all 18 inspections, oldest to newest
10. 10

    Notice Before Transfer or Discharge, Cited in Three Inspections

    Inspectors cited F623 in November 2019, February 2023 and November 2024. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. 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.

    192323232424242424242424252526262626F623 across all 18 inspections, oldest to newest
11. 11

    Quality of Care, Cited in Three Inspections

    Inspectors cited F684 in November 2019, February 2025 and January 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192323232424242424242424252526262626F684 across all 18 inspections, oldest to newest
12. 12

    Pressure Injury Care, Cited in Three Inspections

    Inspectors cited F686 in November 2019, February 2023 and February 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192323232424242424242424252526262626F686 across all 18 inspections, oldest to newest
13. 13

    Dialysis Care, Cited in Three Inspections

    Inspectors cited F698 in November 2019, February 2023 and January 2024. This citation covers care for residents who need dialysis. 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.

    192323232424242424242424252526262626F698 across all 18 inspections, oldest to newest
14. 14

    Nursing Staff Levels, Cited in Three Inspections

    Inspectors cited F725 in November 2019, October 2024 and June 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. 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.

    192323232424242424242424252526262626F725 across all 18 inspections, oldest to newest
15. 15

    Medical Records, Cited in Three Inspections

    Inspectors cited F842 in November 2019, February 2025 and January 2026. This citation covers whether resident records are complete, accurate and kept confidential. 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.

    192323232424242424242424252526262626F842 across all 18 inspections, oldest to newest
16. 16

    Citation F919, Cited in Three Inspections

    Inspectors cited F919 in December 2023, October 2024 and February 2025. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. 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.

    192323232424242424242424252526262626F919 across all 18 inspections, oldest to newest
17. 17

    Dignity and Resident Rights, Cited in Two Inspections

    Inspectors cited F550 in November 2019 and October 2024. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.

    192323232424242424242424252526262626F550 across all 18 inspections, oldest to newest
18. 18

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in February 2023 and February 2025. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. 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.

    192323232424242424242424252526262626F554 across all 18 inspections, oldest to newest
19. 19

    Citation F561, Cited in Two Inspections

    Inspectors cited F561 in February 2023 and June 2026. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 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.

    192323232424242424242424252526262626F561 across all 18 inspections, oldest to newest
20. 20

    Citation F661, Cited in Two Inspections

    Inspectors cited F661 in November 2019 and February 2025. The agency describes it this way: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. 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.

    192323232424242424242424252526262626F661 across all 18 inspections, oldest to newest
21. 21

    Continence and Catheter Care, Cited in Two Inspections

    Inspectors cited F690 in November 2019 and February 2025. This citation covers continence care, catheter care and preventing urinary tract infections. 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.

    192323232424242424242424252526262626F690 across all 18 inspections, oldest to newest
22. 22

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in February 2023 and February 2025. This citation covers oxygen, breathing treatments and other respiratory care. 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.

    192323232424242424242424252526262626F695 across all 18 inspections, oldest to newest
23. 23

    Citation F700, Cited in Two Inspections

    Inspectors cited F700 in November 2019 and February 2025. The agency describes it this way: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 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.

    192323232424242424242424252526262626F700 across all 18 inspections, oldest to newest
24. 24

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in February 2023 and February 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.

    192323232424242424242424252526262626F732 across all 18 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

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

   Infection Control: cited in seven inspections, most seriously at level E.

2. 02

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in six inspections, most seriously at level E.

3. 03

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in five inspections, most seriously at level D.

4. 04

   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 five inspections, most seriously at level E.

5. 05

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in five inspections, most seriously at level E.

6. 06

   What happened after the medication error citation, and how are high-risk drugs double-checked?

   Significant Medication Errors: cited in five inspections, most seriously at level G.

7. 07

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in four inspections, most seriously at level E.

8. 08

   How are medication passes checked, and what happens when an error is found?

   Medication Error Rate: cited in four inspections, most seriously at level E.

9. 09

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in three inspections, most seriously at level D.

10. 10

    When do you transfer or discharge a resident, and how much notice do families get?

    Notice Before Transfer or Discharge: cited in three inspections, most seriously at level E.

11. 11

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in three inspections, most seriously at level G.

12. 12

    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 J.

13. 13

    How is dialysis care coordinated, and who monitors residents before and after treatment?

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

14. 14

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

    Nursing Staff Levels: cited in three inspections, most seriously at level E.

15. 15

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in three inspections, most seriously at level E.

16. 16

    What changed after F919 was cited, and how do you check it now?

    Citation F919: cited in three inspections, most seriously at level E.

17. 17

    How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

    Dignity and Resident Rights: cited in two inspections, most seriously at level E.

18. 18

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

19. 19

    What changed after F561 was cited, and how do you check it now?

    Citation F561: cited in two inspections, most seriously at level E.

20. 20

    What changed after F661 was cited, and how do you check it now?

    Citation F661: cited in two inspections, most seriously at level D.

21. 21

    How is continence care scheduled, and how do you prevent urinary infections?

    Continence and Catheter Care: cited in two inspections, most seriously at level D.

22. 22

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

23. 23

    What changed after F700 was cited, and how do you check it now?

    Citation F700: cited in two inspections, most seriously at level E.

24. 24

    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.

25. 25

    What led to the 2026 fine, and has it been paid?

    A $54,304 civil money penalty was imposed January 13, 2026. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

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 Nov 26, 2019 · 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 3, 2023 · 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 Nov 21, 2023 · 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 Dec 6, 2023 · 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 Jan 24, 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 Jan 31, 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 Jul 12, 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 Jul 29, 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 Aug 30, 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 12, 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 7, 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 Nov 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 Feb 13, 2025 · 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 Apr 10, 2025 · 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 Jan 13, 2026 · 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 Jan 27, 2026 · 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 Jun 12, 2026 · 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 Jul 8, 2026 · 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 · 265477

  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.