Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Moore Few Care Center during CMS and state inspections, most recent first.
A resident with COPD did not receive oxygen therapy as ordered, and staff failed to notify the physician of multiple changes in the resident's respiratory status, including low oxygen saturation, diminished lung sounds, and shortness of breath. The care plan addressing oxygen use was not completed in a timely manner, and the facility lacked policies for change of condition and physician notification. The resident experienced ongoing respiratory distress and was ultimately sent to the emergency department in critical condition.
A resident with chronic conditions experienced ongoing, unrelieved pain due to the facility's failure to consistently assess, monitor, document, and address pain, as well as to notify the physician when pain was not controlled by PRN acetaminophen. Staff did not update the care plan to reflect pain management needs, and the physician was not informed of acute changes, resulting in the resident experiencing increased pain without appropriate intervention.
The facility failed to ensure staff wore appropriate PPE for COVID-19 positive residents, as CNAs and an RN did not use goggles or face shields while providing care. A room identified as COVID-positive lacked necessary signage and PPE, leading to a visitor entering with inadequate protection. The DON and Administrator confirmed expectations for PPE use, but deficiencies persisted.
A facility failed to assess a resident for self-administration of medications, resulting in medications being kept at the bedside without a physician's order. The resident had an albuterol inhaler, saline nasal mist, and artificial tears in an open basket, which were not documented or approved for self-administration. The CMT was unaware of these medications, and the DON confirmed the lack of assessment and documentation.
A facility failed to prevent accidents, resulting in a resident burning their foot with hot chocolate and another resident falling due to a mechanical lift left in their room. The first incident involved serving hot chocolate at 160°F, contrary to the policy of maintaining temperatures below 140°F. The second incident occurred when a CNA left a lift in a resident's room for convenience, leading to a fall. Both incidents highlight lapses in safety protocols and supervision.
The facility failed to properly store respiratory equipment for two residents, leading to deficiencies in oxygen and nebulizer supply management. A resident with respiratory failure had a nasal cannula left unprotected and unlabeled, while another resident's oxygen tubing was found on the floor and nebulizer mouthpiece left open to air. Staff confirmed these practices did not comply with the facility's policy.
A resident did not receive the pneumococcal conjugate vaccine (PCV) 13, 15, or 20, despite having a signed consent form. The resident's EMR showed they had previously received the Pneumovax23 vaccine, but there was no record of the PCV vaccine being administered or a physician's order for it. The DON confirmed the oversight, acknowledging the vaccine should have been given.
A resident with multiple medical conditions slid out of their wheelchair during transport in the facility's van due to the driver not using a seatbelt. The incident occurred when the driver had to make a sudden stop, and the facility lacked a specific policy for van transportation.
Failure to Provide Safe and Appropriate Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide respiratory care consistent with standards of practice for a resident with chronic obstructive pulmonary disease (COPD). Staff did not consistently administer oxygen as ordered by the physician, with multiple instances documented where the resident received either less or more oxygen than prescribed. Additionally, staff failed to notify the physician of significant changes in the resident's respiratory status, including reduced oxygen saturation levels, diminished lung sounds, shortness of breath, and the presence of cough. These changes were repeatedly documented in the resident's records without evidence of timely physician notification. The resident's care plan addressing oxygen usage and respiratory care was not created in a timely manner, being completed 24 days after admission and 11 days after the completion of the admission Minimum Data Set (MDS). Throughout the resident's stay, there were multiple documented episodes of respiratory distress, low oxygen saturation, and other symptoms such as cough and diminished lung sounds. Despite these findings, staff did not consistently assess, document, or communicate these changes to the physician as required. Interviews with staff revealed a lack of clarity regarding the process for physician notification and change of condition, with some staff relying on informal methods such as sticky notes rather than direct communication. The facility did not provide policies regarding change of condition procedures or physician notification when requested. The resident ultimately experienced severe respiratory distress, became cyanotic, and was sent to the emergency department, where cardiac arrest occurred. Interviews with staff, other residents, and the physician confirmed that the resident had ongoing respiratory issues and that appropriate notification and care planning were not consistently performed.
Failure to Implement Effective Pain Management and Physician Notification
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with chronic conditions, including COPD and peripheral vascular disease. Despite physician orders for pain monitoring every shift and PRN acetaminophen for pain, staff did not consistently assess, monitor, or document the resident's pain levels and interventions. There were multiple instances where pain assessments were either not completed or not documented, and pain interventions were not recorded for moderate pain levels. Additionally, the resident's care plan did not address pain management, despite ongoing complaints and documented pain episodes. Throughout the resident's stay, there were repeated episodes of increased and unrelieved pain, with pain scores reaching as high as 10 out of 10. Staff administered acetaminophen as ordered, but when the medication was ineffective or the resident continued to report high pain levels, there was no documentation of physician notification or further action taken. On several occasions, staff noted that the PRN medication was not effective, yet did not escalate the issue or seek alternative interventions. Interviews with staff confirmed that pain complaints were often written down for the physician to review later, rather than being communicated promptly, and that the physician was not notified of acute changes in the resident's pain status. The physician and facility leadership confirmed that they were not made aware of the resident's ongoing pain issues or the ineffectiveness of the prescribed pain regimen. Staff interviews revealed a lack of adherence to the facility's pain management policy, which required assessment, documentation, care planning, and physician notification for unrelieved pain. The failure to accurately assess, monitor, address, care plan, and notify the physician of increased and unrelieved pain resulted in the resident experiencing ongoing pain without appropriate intervention.
Failure to Adhere to PPE Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure staff adhered to the policy and standards for wearing appropriate Personal Protective Equipment (PPE) for residents who tested positive for COVID-19. Observations revealed that Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) did not wear goggles or face shields while providing care to residents under transmission-based precautions for COVID-19. Specifically, CNAs entered the rooms of COVID-positive residents without the required PPE, and one CNA admitted to testing positive for COVID-19 but continued working with COVID-positive residents. Additionally, the RN stated that goggles and face shields were unavailable for use. Further deficiencies were noted when a room identified as a COVID-positive area lacked transmission-based precautions signage and a PPE cart. A visitor was observed exiting the room wearing only a surgical mask, unaware of the required PPE. The Director of Nursing (DON) and the Administrator confirmed that staff were expected to follow PPE protocols, and the DON acknowledged the absence of necessary signage and PPE outside the COVID-positive room. The Administrator also stated that COVID-positive staff members, whether symptomatic or asymptomatic, were asked not to work.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for safety and obtained a physician's order prior to self-administration of medication. During observations, medications were found at the bedside of a resident who had not been assessed for self-administration. The medications included an albuterol inhaler, saline nasal mist, and artificial tears, which were kept in an open basket on the resident's bedside table. The resident mentioned that their family brought the eye drops and saline spray, and they kept the inhaler nearby in case the facility could not provide the medications. The Certified Medication Technician (CMT) was unaware of the medications in the resident's room and assumed there was an order for the inhaler to be kept at the bedside. Upon checking, no such order was found, and the resident had not informed the CMT about taking these medications. The Director of Nursing (DON) confirmed that the resident had not been assessed for self-administration, and there was no documentation or physician's order for the medications to be stored at the bedside. This oversight led to a deficiency in ensuring the resident's safety and proper medication management.
Facility Fails to Prevent Accidents Involving Hot Liquids and Equipment
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, resulting in two separate incidents. In the first incident, a resident with a history of cerebral infarction, ankylosing spondylitis, cognitive communication deficit, and dementia suffered a burn on the foot from hot chocolate. The resident, who was wheelchair-bound and required supervision for eating, knocked the hot chocolate off the table, leading to a burn. The facility's policy on hot liquids required monitoring and maintaining serving temperatures below 140 degrees Fahrenheit, but observations showed the hot chocolate was served at 160 degrees Fahrenheit, indicating a failure to adhere to the policy. In the second incident, a resident with dementia, difficulty walking, and unsteadiness on feet fell in their room due to a mechanical lift being left there. The resident, who used a wheelchair and required moderate assistance with daily activities, was found on the floor with legs draped over the lift's base. The lift was left in the room by a CNA for convenience, despite the facility's policy against leaving equipment in residents' rooms. The CNA, who was new to the facility but experienced, admitted to leaving the lift in the room, which was against the training received. Both incidents highlight the facility's failure to implement effective processes to minimize accident hazards. The first incident involved inadequate monitoring of hot liquid temperatures, while the second involved improper storage of mechanical equipment, both leading to resident harm. These deficiencies were identified through observations, interviews, and record reviews, indicating lapses in adherence to established safety protocols.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care per standards of practice by not ensuring proper storage of oxygen and nebulizer supplies for two residents. Resident #3, who has acute and chronic respiratory failure with hypoxia, had a nasal cannula that was repeatedly observed draped on the oxygen concentrator without being labeled, dated, or stored in a protective bag. This was contrary to the facility's policy, which requires such equipment to be stored in plastic bags when not in use and changed weekly. Similarly, Resident #28, who has multiple respiratory and cognitive conditions, had oxygen tubing observed on the floor and a nebulizer mouthpiece left open to air in a Styrofoam cup, both without labels. The facility's policy mandates that oxygen tubing and nebulizer equipment be stored in plastic bags and labeled with the date of change. Observations confirmed these deficiencies, and interviews with staff, including an LPN and the Director of Nursing, acknowledged the failure to adhere to the facility's policy for respiratory equipment management.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that all residents who wished to receive pneumococcal vaccines were administered the vaccines as requested. Specifically, one resident, identified as Resident #9, did not receive the pneumococcal conjugate vaccine (PCV) 13, 15, or 20, despite having a signed consent form for the vaccination. The resident's electronic medical record (EMR) indicated that they had previously received the Pneumovax23 vaccine on 11/30/18, but there was no record of the PCV vaccine being administered, nor was there a physician's order for it in the EMR. During an interview, the Director of Nursing, who also served as the Infection Control Preventionist, confirmed that the resident's vaccination consent was signed, but the vaccination was not given, acknowledging that it should have been administered. This oversight was identified during a review of the facility's policy on immunization records, which outlined the adult pneumococcal vaccination recommendations.
Failure to Secure Resident in Wheelchair During Transport
Penalty
Summary
The facility failed to ensure all residents were kept free from possible accident hazards when a staff member did not fully secure a resident in a wheelchair during transport in the facility's van. The incident occurred when the van driver had to make a sudden stop to avoid a collision, causing the resident to slide out of the wheelchair and onto the van floor. The wheelchair remained secured to the van floor, but the resident was not restrained with a seatbelt, leading to the fall. The resident involved had multiple medical conditions, including end-stage renal disease, stroke, congestive heart failure, muscle weakness, and legal blindness. The resident was dependent on staff for transfers and used a wheelchair for mobility. On the day of the incident, the resident was being transported to a dialysis appointment when the sudden stop occurred, resulting in the resident sliding out of the wheelchair. Interviews with staff revealed that the van driver had been trained to use four straps to secure the wheelchair but was incorrectly informed that seatbelts were only necessary for out-of-town trips. The facility did not have a specific policy regarding van transportation, which contributed to the improper securing of the resident. The incident was reported to the Department of Health and Senior Services, and an internal investigation confirmed that the resident was not appropriately restrained during transport.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nevada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Nevada | 1.2 mi | ★★★★★ | 0 | 0 |
| Nathan Richard Health Care Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Community Springs Healthcare Facility | 18.9 mi | ★★★★★ | 0 | 0 |
| Medicalodges Fort Scott | 19.3 mi | ★★★★★ | 8 | 0 |
| Truman Healthcare & Rehabilitation Center | 22.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.