Holden Manor Health & Rehabilitation
2005 South Lexington · Holden, MO · 64040 · 8167324138
52 certified beds For profit - Corporation Chain: Mo Op Holdco, LLC
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Total nurse staffing below 3.0 hours per resident-day
2.89 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
82% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 2.89 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.57 | 0.55–0.75 |
| Weekend hours / resident-day | 2.60 | ≈ weekday level |
| Nursing turnover / year | 82% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (38 in the current record)
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Potential for harm · D January 22, 2026 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Past Non-Compliance · Resident Rights
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Potential for harm · D August 2, 2024
Honor the resident's right to manage his or her financial affairs.
Corrected September 15, 2024 · Resident Rights
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Potential for harm · E August 2, 2024
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected September 15, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected September 15, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
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 September 15, 2024 · Resident Rights
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Potential for harm · E August 2, 2024
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 September 15, 2024 · Resident Rights
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Potential for harm · D August 2, 2024
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected September 15, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 2, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected September 15, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 2, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 15, 2024 · Quality of Life and Care
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Potential for harm · D August 2, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected September 15, 2024 · Quality of Life and Care
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Potential for harm · D August 2, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 15, 2024 · Pharmacy Service
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Potential for harm · D August 2, 2024
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 September 15, 2024 · Pharmacy Service
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Potential for harm · E August 2, 2024
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 September 15, 2024 · Pharmacy Service
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Potential for harm · E August 2, 2024
Ensure 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.
Corrected September 15, 2024 · Nutrition and Dietary
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Potential for harm · E August 2, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected September 15, 2024 · Nutrition and Dietary
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Potential for harm · E August 2, 2024
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected September 15, 2024 · Nutrition and Dietary
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Potential for harm · F August 2, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 15, 2024 · Nutrition and Dietary
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Potential for harm · E August 2, 2024
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected September 15, 2024 · Nutrition and Dietary
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Potential for harm · F August 2, 2024
Provide and implement an infection prevention and control program.
Corrected September 15, 2024 · Infection Control
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Potential for harm · E August 2, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected September 15, 2024 · Infection Control
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Potential for harm · E August 2, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected September 15, 2024 · Environmental
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Potential for harm · D January 13, 2023
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected February 21, 2023 · Resident Rights
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Potential for harm · D January 13, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 13, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 13, 2023
Respond appropriately to all alleged violations.
Corrected February 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 265739 · certified since May 14, 2002. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.