The Vardell Report.Troy Manor

Across 6 inspections from October 2020 to June 2026, state surveyors documented 66 findings at Troy Manor; 66 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

6

2020–2026, standard and complaint

Findings

66

Deficiencies cited by state inspectors

Corrected

66

Of 66 findings, with a recorded correction date

Penalties

4

2 fines; payment not published, 2 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. Jun 42026

   Standard health inspection

   10 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jul 15, 2026
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Jul 15, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Jul 15, 2026
   • 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 Jul 15, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jul 15, 2026
   • 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 Jul 15, 2026
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 15, 2026
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jul 15, 2026
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jul 15, 2026
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jul 15, 2026

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

2. May 142025

   Complaint investigation

   3 findings

   • 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 May 5, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 5, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 11, 2025

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

3. Nov 192024

   Complaint investigation

   1 finding

   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Dec 16, 2024

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

4. Oct 32024

   Complaint investigation

   8 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Nov 11, 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 ENo actual harm, potential for moreCorrected Nov 11, 2024
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
   • F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 11, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 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 Nov 11, 2024

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

5. Apr 92024

   Standard health inspection

   17 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level KImmediate jeopardyCorrected May 20, 2024
   • 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 May 20, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected May 20, 2024
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected May 20, 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 May 20, 2024
   • 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, 2024
   • 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 May 20, 2024
   • F728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Level ENo actual harm, potential for moreCorrected May 20, 2024
   • 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 May 20, 2024
   • 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 ENo actual harm, potential for moreCorrected May 20, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 20, 2024
   • 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 May 20, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 20, 2024
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 20, 2024
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected May 20, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level BPotential for minimal harmCorrected May 20, 2024
   • 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 BPotential for minimal harmCorrected May 20, 2024

   Enforcement Action

   Civil money penalty, $20,429 imposed April 9, 2024. 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 April 9, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 9, 2024. Status: Closed, May 20, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 9, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $84,256 imposed October 3, 2024. 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 April 9, 2024, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed October 3, 2024. Status: Closed, December 16, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 9, 2024, the nearest before the penalty date.

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

6. Oct 282020

   Standard health inspection

   27 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level KImmediate jeopardyCorrected Dec 10, 2020
   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level GActual harmCorrected Dec 10, 2020
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Dec 10, 2020
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Dec 10, 2020
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 27, 2021
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Dec 10, 2020
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Dec 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 Dec 10, 2020
   • 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 Dec 10, 2020
   • 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 Dec 10, 2020
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jan 27, 2021
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level ENo actual harm, potential for moreCorrected Dec 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 ENo actual harm, potential for moreCorrected Dec 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 Dec 10, 2020
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Dec 10, 2020
   • 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 ENo actual harm, potential for moreCorrected Dec 10, 2020
   • 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 Dec 10, 2020
   • 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 Dec 10, 2020
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 10, 2020
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level DNo actual harm, potential for moreCorrected Dec 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

   Food Quality and Temperature, Cited in Four Inspections

   Inspectors cited F804 in October 2020, October 2024, November 2024 and June 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.

   202424242526F804 across all 6 inspections, oldest to newest
2. 2

   Infection Control, Cited in Four Inspections

   Inspectors cited F880 in October 2020, April 2024, October 2024 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202424242526F880 across all 6 inspections, oldest to newest
3. 3

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in October 2020, October 2024 and May 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202424242526F600 across all 6 inspections, oldest to newest
4. 4

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in October 2020, October 2024 and May 2025. 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   202424242526F609 across all 6 inspections, oldest to newest
5. 5

   Investigating Alleged Violations, Cited in Three Inspections

   Inspectors cited F610 in October 2020, October 2024 and May 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. 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.

   202424242526F610 across all 6 inspections, oldest to newest
6. 6

   Help With Daily Living, Cited in Three Inspections

   Inspectors cited F677 in October 2020, April 2024 and June 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.

   202424242526F677 across all 6 inspections, oldest to newest
7. 7

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in October 2020, April 2024 and October 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.

   202424242526F689 across all 6 inspections, oldest to newest
8. 8

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in October 2020, April 2024 and June 2026. This citation covers how food is stored, prepared and served. 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.

   202424242526F812 across all 6 inspections, oldest to newest
9. 9

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in October 2020 and April 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.

   202424242526F623 across all 6 inspections, oldest to newest
10. 10

    Citation F625, Cited in Two Inspections

    Inspectors cited F625 in October 2020 and April 2024. The agency describes it this way: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. 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.

    202424242526F625 across all 6 inspections, oldest to newest
11. 11

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in October 2020 and April 2024. 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.

    202424242526F656 across all 6 inspections, oldest to newest
12. 12

    Citation F700, Cited in Two Inspections

    Inspectors cited F700 in October 2020 and April 2024. 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.

    202424242526F700 across all 6 inspections, oldest to newest
13. 13

    Nursing Staff Levels, Cited in Two Inspections

    Inspectors cited F725 in October 2020 and April 2024. 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.

    202424242526F725 across all 6 inspections, oldest to newest
14. 14

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in April 2024 and June 2026. This citation covers whether residents are free from significant medication errors. 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.

    202424242526F760 across all 6 inspections, oldest to newest
15. 15

    Citation F909, Cited in Two Inspections

    Inspectors cited F909 in October 2020 and April 2024. The agency describes it this way: Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. 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.

    202424242526F909 across all 6 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

   May we try a meal, and how do you check food temperature by the time it reaches residents?

   Food Quality and Temperature: cited in four inspections, most seriously at level F.

2. 02

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

   Infection Control: cited in four inspections, most seriously at level K.

3. 03

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in three inspections, most seriously at level K.

4. 04

   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 E.

5. 05

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in three inspections, most seriously at level E.

6. 06

   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 three inspections, most seriously at level E.

7. 07

   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 three inspections, most seriously at level E.

8. 08

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

9. 09

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

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

10. 10

    What changed after F625 was cited, and how do you check it now?

    Citation F625: cited in two inspections, most seriously at level E.

11. 11

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

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

12. 12

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

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

13. 13

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

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

14. 14

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

    Significant Medication Errors: cited in two inspections, most seriously at level D.

15. 15

    What changed after F909 was cited, and how do you check it now?

    Citation F909: cited in two inspections, most seriously at level E.

16. 16

    What led to the 2024 fine, and has it been paid?

    An $84,256 civil money penalty was imposed October 3, 2024. CMS publishes the fine, not whether it has been paid. The record holds four 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 Oct 28, 2020 · 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 9, 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 3, 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 19, 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 May 14, 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 Jun 4, 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 · 265702

  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.