Cycle 1
Health 2024-11-14 · Fire 2024-11-14
26 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Mexico, MO
Pin Oaks Living Center
2-star overall rating with 1-star inspections with abuse icon flag with $21,450 in total fines with 26 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1525 West Monroe, Mexico, MO
(573) 581-7261
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1992-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.89
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,109
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.60% · Performance 22.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.42% · Performance 8.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.11
Baseline 65.08% · Performance 59.16% · Measure score 1.11 · Achievement 1.11 · Improvement 0.97
Adjusted total nurse staffing
4.43
Baseline 3.21 hours · Performance 4.34 hours · Measure score 4.43 · Achievement 4.43 · Improvement 3.88
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 8% · Lower 95% interval 6.38% |
| Discharge to community | 52.38% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 49.52% · Lower 95% interval 43.41% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.93% |
95.27%
7.3 pts worse
|
Numerator 51 · Denominator 58 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 58 |
| Discharge self-care score | 31.71% |
53.69%
22 pts worse
|
Numerator 13 · Denominator 41 |
| Discharge mobility score | 48.78% |
50.94%
2.2 pts worse
|
Numerator 20 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 1.86% |
| Healthcare-associated infections requiring hospitalization | 8.54% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 11.43% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 9.18% |
8.2%
1 pts better
|
Numerator 9 · Denominator 98 |
| Staff flu vaccination coverage | 23.33% |
42%
18.7 pts worse
|
Numerator 21 · Denominator 90 |
| Discharge function score | 51.22% |
56.45%
5.2 pts worse
|
Numerator 21 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 26 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 12 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
84.8%
4 pts better
|
93.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 90.5% · Q3 91.5% · Q4 77.9% · 4Q avg 88.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
90.9%
6.2 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
4.1%
1.5 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.2% · Q3 1.4% · Q4 2.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
14.7%
14.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.5%
2.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 3.2% · Q4 5.7% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.6% |
25.3%
8.3 pts worse
|
19.6%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 32.8% · Q3 32.3% · Q4 34.7% · 4Q avg 33.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.2% |
25.0%
1.2 pts worse
|
16.7%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.4% · Q3 28.1% · Q4 31.1% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.5% |
20.3%
1.8 pts better
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 21.1% · Q3 18.3% · Q4 17.8% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
19.8%
4 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 12.5% · Q3 14.5% · Q4 21.7% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.4%
0.3 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
18.1%
4.2 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.8% · Q3 27.5% · Q4 17.3% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.0%
1.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.3% · Q3 7.0% · Q4 7.2% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.2% |
66.4%
6.2 pts worse
|
81.7%
21.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.0% · Q2 65.9% · Q3 61.8% · Q4 53.6% · 4Q avg 60.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
13.4%
5.7 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.2%
0.3 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.7% · Q3 1.8% · Q4 2.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.2% |
63.5%
5.7 pts better
|
79.7%
10.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
25.3%
10.3 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.9% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-08-09 · Fire 2019-08-09
21 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-23
F · Potential for more than minimal harm
2023-02-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-10
F · Potential for more than minimal harm
2023-02-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-10
F · Potential for more than minimal harm
2023-02-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-10
F · Potential for more than minimal harm
2019-08-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-10-10
F · Potential for more than minimal harm
2019-08-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-10
Inspection history
Recent health citations
G · Actual harm
2026-01-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-28
E · Potential for more than minimal harm
2026-01-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-02-10
C · Minimal harm
2026-01-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-28
G · Actual harm
2025-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-10
G · Actual harm
2025-11-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-11-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-18
C · Minimal harm
2025-11-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-28
F · Potential for more than minimal harm
2024-11-14
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-11-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-14
F909 · Environmental Deficiencies
Health
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.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-10-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-10-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-10
E · Potential for more than minimal harm
2023-11-08
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-11-24
G · Actual harm
2023-07-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-07-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-12
G · Actual harm
2023-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-13
E · Potential for more than minimal harm
2023-03-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-02-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-02-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-10
B · Minimal harm
2023-02-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-10
B · Minimal harm
2023-02-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-10
B · Minimal harm
2023-02-23
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-10
E · Potential for more than minimal harm
2019-08-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-10
C · Minimal harm
2019-08-09
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-10-10
B · Minimal harm
2019-08-09
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-10-10
Penalties and ownership
What sits behind the stars
$21,450
2023-06-13
Fine
Fine · fine $21,450
Fine
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Lincoln, James
Operational/Managerial Control · Individual
Ltc Management Services LLC
Operational/Managerial Control · Organization
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