Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
89% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 4
Date: Jul 14, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding residents' inability to make confidential phone calls to the state abuse and neglect hotline and incidents of physical abuse involving residents.
Complaint Details
The complaint investigation was substantiated. The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline and failed to protect residents from physical abuse. Immediate Jeopardy was identified related to abuse incidents involving Resident #18 and Resident #7. The Immediate Jeopardy was removed on 07/14/2025 after corrective actions were verified onsite.
Findings
The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline from facility phones, impacting all residents. Additionally, the facility failed to protect residents from physical abuse, including an incident where a resident was rolled out of bed multiple times by a staff member resulting in a fracture, and another incident of resident-to-resident physical abuse. The facility also failed to conduct a thorough investigation of the abuse allegations.
Deficiencies (4)
Facility phones would not allow outgoing calls to the Missouri abuse and neglect hotline, impacting residents' rights to confidential communication.
Failure to protect residents from physical abuse, including an incident where LPN A rolled Resident #18 out of bed multiple times causing a fractured tibial plateau.
Failure to protect Resident #7 from physical abuse when Resident #27 hit him/her on the back of the head.
Failure to thoroughly investigate an allegation of abuse when Resident #18 reported being abused by LPN A resulting in injury.
Report Facts
Facility census: 56
Date of incident: 2025
Immediate Jeopardy removal date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in physical abuse incident involving Resident #18 and failure to properly investigate the incident |
| Certified Medication Technician A | CMT | Reported abuse hotline phone not working and resident abuse allegation |
| Administrator | Attempted to call abuse hotline unsuccessfully and acknowledged failure to investigate abuse allegations thoroughly | |
| Assistant Director of Nursing | ADON | Attempted to call abuse hotline unsuccessfully and involved in abuse incident response |
| Director of Nursing | DON | Attempted to call abuse hotline unsuccessfully and acknowledged residents' rights to private calls |
| LPN B | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to residents' rights to make confidential phone calls to the state abuse and neglect hotline and to assess allegations of physical abuse involving residents.
Findings
The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline from facility phones, impacting multiple residents. Additionally, the facility failed to protect residents from physical abuse, including an incident where a resident was rolled out of bed multiple times by staff resulting in a fracture, and another incident involving resident-to-resident physical abuse.
Deficiencies (2)
Facility phones would not allow outgoing calls to the Missouri abuse and neglect hotline, impacting residents' rights to confidential communication.
Failure to protect two residents from physical abuse, including a resident being rolled out of bed multiple times by staff resulting in a fracture and another resident being hit on the back of the head by another resident.
Report Facts
Facility census: 56
Residents affected: 3
Residents affected: 2
Immediate Jeopardy duration: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in physical abuse incident with Resident #18 resulting in fracture |
| Certified Medication Technician A | Certified Medication Technician | Reported knowledge of phone issue from Resident #109 and did not immediately report |
| Administrator | Attempted to call hotline unsuccessfully from facility phones; acknowledged phone issue and abuse hotline access rights | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Attempted to call hotline unsuccessfully and commented on phone system issues |
| Director of Nursing | Director of Nursing (DON) | Attempted to call hotline unsuccessfully and commented on residents' rights |
| LPN B | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident involving Resident #7 and Resident #27 |
| Certified Nurses Aide A | Certified Nurses Aide | Assisted resident after fall and provided observations related to abuse incident |
| Certified Medication Technician C | Certified Medication Technician | Assisted resident after fall and provided observations related to abuse incident |
Inspection Report
Routine
Census: 53
Deficiencies: 4
Date: May 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to a safe, clean, comfortable, and homelike environment, focusing on noise levels, staff intervention, and environmental safety concerns.
Findings
The facility failed to provide a comfortable and homelike environment for four sampled residents due to loud and disruptive noise levels in the dining room, lack of staff intervention during resident yelling, and a door to the smoking area that slammed shut causing distress. Several residents and staff reported concerns about noise, overstimulation, and inadequate staff training to manage mental health residents.
Deficiencies (4)
Failed to ensure sound levels were not loud and uncomfortable in the dining room.
Staff failed to intervene when a resident was yelling.
Facility failed to ensure the door to the smoking area did not slam shut causing distress to a resident.
Facility did not provide the requested policy regarding a comfortable and homelike environment.
Report Facts
Residents sampled: 20
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide (CNA) A | Reported no education about dealing with mental health residents and fear of intervening with a yelling resident | |
| Certified Nurses Aide (CNA) B | Reported no training and inability to manage noise and resident distress | |
| Administrator | Stated expectations for peaceful quiet areas and staff efforts to manage noise |
Inspection Report
Routine
Census: 53
Deficiencies: 10
Date: May 30, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, care planning, infection control, staff training, food safety, and facility environment standards.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and appropriate room change notices, incomplete and untimely Minimum Data Set (MDS) assessments and care plans, inadequate staff training especially for psychiatric care, unsanitary kitchen conditions, failure to maintain infection control with nebulizer and CPAP equipment, and an outdated facility-wide assessment. Several residents expressed distress due to noise, inappropriate behavior of other residents, and environmental issues.
Deficiencies (10)
Failed to provide a dignified existence for residents by allowing inappropriate exposure and disruptive behavior in common areas without staff intervention.
Failed to provide written notice to residents regarding room changes, causing emotional distress.
Failed to clarify and update Resident #11's Do Not Resuscitate (DNR) status accurately in medical orders.
Failed to provide a safe, clean, comfortable, and homelike environment including managing noise levels and preventing door slamming.
Failed to complete timely and accurate Minimum Data Set (MDS) assessments and care plans for several residents.
Failed to train staff adequately to care for residents with behavioral health needs, resulting in unsafe conditions for some residents.
Failed to maintain kitchen sanitation including dirty floors, vents, dust-covered equipment, outdated food, improper chemical storage, and incomplete dishwasher sanitizer logs.
Failed to update and maintain an accurate facility-wide assessment reflecting current resident needs and staffing.
Failed to maintain infection control by allowing nebulizer machines, tubing, and CPAP masks to rest on the floor without barriers.
Failed to provide required nurse aide education and competency evaluations annually, and lacked a tracking system for training hours.
Report Facts
Residents affected: 3
Facility census: 53
Residents with behavior health needs: 32
Residents sampled: 14
Nurse aide education hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Responsible for staff education and training |
| Administrator | Facility Administrator | Provided statements on facility expectations and deficiencies |
| Director of Nursing | Director of Nursing (DON) | Provided statements on MDS, care plans, and staff training |
| Certified Nurse Aide A | Certified Nurse Aide | Mentioned in relation to lack of training and response to behavioral incidents |
| Certified Nurse Aide B | Certified Nurse Aide | Mentioned in relation to lack of training and response to behavioral incidents |
| Dietary Manager | Dietary Manager | Provided statements on kitchen sanitation and maintenance |
| Registered Dietitian | Registered Dietitian | Provided statements on kitchen sanitation expectations |
| Maintenance Department Staff | Maintenance Staff | Provided statements on cleaning vents and maintenance requests |
| Infection Preventionist | Infection Preventionist | Provided statements on infection control for nebulizer and CPAP equipment |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident altercation where Resident 1 slapped Resident 2 on 12/18/2023, and the facility failed to report the incident to the Department of Health and Senior Services within the required two-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not report a resident-to-resident abuse incident within two hours as required. The allegation was substantiated by interviews with staff, residents, and review of medical records. The Assistant Director of Nursing, Administrator, and Director of Nursing acknowledged the failure to report timely.
Findings
The facility failed to timely report a suspected abuse incident involving Resident 1 slapping Resident 2. Interviews and record reviews confirmed the incident and that staff did not report it within the mandated two-hour period as required by facility policy and state regulations.
Deficiencies (1)
Failure to timely report suspected abuse of a resident to the Department of Health and Senior Services within the required two-hour timeframe.
Report Facts
Census: 21
Date of incident: Dec 18, 2023
Date of interviews: Dec 25, 2023
Date of survey completion: Dec 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Documented the incident of Resident 1 slapping Resident 2 | |
| Certified Nurse Aid (CNA) A | Witnessed and reported the incident to LPN A | |
| Assistant Director of Nursing (ADON) | Interviewed and acknowledged failure to report incident timely | |
| Administrator | Interviewed and acknowledged failure to report incident timely | |
| Director of Nursing (DON) | Interviewed and acknowledged failure to report incident timely |
Inspection Report
Routine
Census: 16
Deficiencies: 11
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification procedures, care planning, fall prevention, staffing, nutrition, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure physician signatures on advance directives, failure to provide required Medicare beneficiary notices, inadequate grievance procedures, failure to provide timely transfer/discharge notices and bed hold policies, incomplete and untimely care plan updates, inadequate fall prevention interventions, insufficient RN coverage, failure to follow menu recipes, and unsafe parking lot conditions.
Deficiencies (11)
Failure to ensure physician signatures on Outside of Hospital Do Not Resuscitate (OHDNR) forms and incapacity forms for sampled residents.
Failure to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 form to residents.
Failure to assure residents have the right to file grievances in writing, anonymously, and to have grievance contact information and timelines posted and accessible.
Failure to provide written notice of transfer or discharge and reasons for transfer in a language residents or responsible parties understand.
Failure to provide bed hold policy notification to residents or responsible parties when residents transferred to hospital.
Failure to develop and implement complete, individualized care plans addressing resident needs including vision changes and use of Warfarin.
Failure to update care plans with new interventions after resident falls and fluid restrictions.
Failure to provide an environment free from accident hazards and provide adequate supervision to prevent falls for residents at risk.
Failure to provide RN coverage for eight consecutive hours per day, seven days a week.
Failure to follow pre-prepared menus and recipes to meet nutritional needs of residents.
Failure to maintain walking surfaces free from obstructions and hazards, specifically holes and uneven asphalt in handicapped parking spot.
Report Facts
Facility census: 16
Fall risk score: 17
Fall risk score: 18
Fluid restriction: 1000
Biscuits: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Interviewed regarding advance directive and care plan deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including grievance process, care plans, RN coverage |
| Social Services Designee | Social Services Designee | Interviewed regarding advance directive and grievance process |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding beneficiary notices, care plans, and grievance process |
| Administrator | Administrator | Interviewed regarding beneficiary notices and RN coverage |
| CNA A | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| CNA B | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| CNA C | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| Kitchen Manager | Kitchen Manager | Interviewed regarding menu substitution and recipe adherence |
| Registered Dietician | Registered Dietician | Interviewed regarding menu planning and recipe adherence |
| Maintenance Director | Maintenance Director | Interviewed regarding parking lot repairs |
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