Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
92 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure accurate documentation and administration of narcotic medication for a sampled resident.
Complaint Details
Complaint number 2634694 triggered the investigation into narcotic medication administration and documentation discrepancies.
Findings
The facility failed to ensure the physician's orders for narcotic medication matched the narcotic sheet and Medication Administration Record (MAR), failed to accurately document narcotic administration on the MAR, and failed to follow policy for corrections on the narcotic sheet. Discrepancies were found in medication counts and documentation, including altered records and missing signatures.
Deficiencies (3)
Failure to ensure physician's order for narcotic medication was accurately shown on the narcotic sheet and MAR.
Failure to ensure nurse accurately documented narcotic medications administered on the MAR.
Failure to follow policy and procedure for corrections made on the narcotic sheet.
Report Facts
Residents Affected: 8
Facility Census: 92
Medication tablets delivered: 30
Medication tablets documented: 20
Medication tablets administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Described narcotic medication administration process and discrepancies |
| Registered Nurse A | Registered Nurse | Described in-service training and narcotic administration documentation requirements |
| Director of Nursing | Director of Nursing | Provided expectations for narcotic order verification and documentation, and discussed audit findings |
| Administrator | Administrator | Discussed narcotic sheet and MAR discrepancies and corrective expectations |
Inspection Report
Routine
Census: 45
Deficiencies: 7
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, environment safety, medication security, food service safety, and quality assurance.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident participation in care planning, inadequate notification of Medicare non-coverage, failure to maintain a clean and safe environment, untimely care plan updates, unsecured medication cart, unsanitary kitchen conditions, and incomplete attendance of required members in the Quality Assessment and Performance Improvement committee.
Deficiencies (7)
Failed to ensure a resident was provided opportunities to make decisions in their best interest for the Care Plan process.
Failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident.
Failed to maintain the physical environment in a safe, clean, comfortable and homelike manner on 200 Hall and shared lounge areas.
Failed to develop a Comprehensive Care Plan within 7 days of a significant change in resident's status.
Failed to ensure an environment free from accident hazards by leaving a treatment cart unlocked in a resident lounge area.
Failed to store, prepare, distribute, and serve food in accordance with professional standards due to unsanitary kitchen conditions.
Failed to maintain a Quality Assessment and Performance Improvement committee with required members present at all quarterly meetings.
Report Facts
Residents affected: 3
Residents affected: 2
Census: 45
Days late for care plan update: 26
Quarterly meetings missing required members: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Interviewed regarding Resident #64's decision-making capacity and care planning | |
| Social Worker #2 | Interviewed regarding Resident #64's Durable Power of Attorney and care planning participation | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding care plan timeliness, environmental observations, and QAPI committee attendance |
| Facilities Director | Facilities Director | Interviewed regarding housekeeping policies and environmental cleanliness |
| Housekeeping Supervisor #5 | Housekeeping Supervisor | Accompanied surveyor during environmental tour and discussed cleaning expectations |
| RN Charge Nurse #4 | Registered Nurse Charge Nurse | Interviewed regarding unsecured treatment cart |
| Chef #3 | Chef | Interviewed regarding kitchen cleanliness and cleaning responsibilities |
| Director of Dining Services (DDS) | Director of Dining Services | Interviewed regarding kitchen cleanliness and importance of sanitation |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify the resident's responsible party prior to starting a new medication for a sampled resident.
Complaint Details
The complaint was substantiated. The resident's DPOA was not notified prior to administration of Memantine, a new medication. The DPOA found out about the medication from the pharmacy bill and requested discontinuation. The facility held a conference call with the DPOA to discuss the grievance.
Findings
The facility failed to notify the resident's Durable Power of Attorney (DPOA) before administering a new medication, Memantine, to Resident #2. The facility provided in-service education to nursing staff on notification responsibilities and corrected the deficiency by 6/21/24.
Deficiencies (1)
Failure to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident.
Report Facts
Residents present: 88
Dates of medication administration: Memantine administered between 5/10/24 and 6/17/24 as per Medication Administration Records
Date of in-service education: Nursing staff in-serviced on notification responsibilities on 6/21/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Interviewed regarding notification responsibilities for medication changes | |
| Administrator | Interviewed regarding notification failure and staff in-service | |
| Director of Nurses | DON | Interviewed regarding verbal orders and notification procedures |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The inspection was conducted following a complaint alleging that the facility failed to protect a resident from physical abuse and intimidation, specifically regarding a forced shower incident on 1/25/24.
Complaint Details
The complaint investigation was substantiated. The resident reported being forcibly showered after refusing, resulting in bruises. Staff interviews confirmed the forced shower and improper transfer without a gait belt. The facility acknowledged the abuse and corrected the immediate jeopardy before the investigation.
Findings
The facility failed to protect one resident from physical abuse when staff forcibly gave the resident a shower after the resident refused, resulting in bruising. Additionally, the facility failed to use a gait belt during a transfer, which was against policy and best practice. The immediate jeopardy was corrected prior to the investigation.
Deficiencies (2)
Failed to protect a resident from physical abuse by forcibly showering the resident against their will, causing bruising.
Failed to provide safe transfer assistance by not using a gait belt during transfer of the resident, resulting in bruising.
Report Facts
Residents affected: 1
Facility census: 87
Staff involved: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in forcibly showering the resident and transfer without gait belt. |
| CNA A | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| CNA B | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| CNA C | Certified Nurses Aide | Assisted in showering the resident and transfer without gait belt. |
| Administrator | Notified of immediate jeopardy and acknowledged abuse. | |
| Director of Nursing | Director of Nursing | Involved in investigation and acknowledged abuse. |
| NP A | Nurse Practitioner | Ordered psychiatric evaluation and stated expectation that residents not be forced to shower. |
Inspection Report
Routine
Census: 80
Deficiencies: 11
Date: Jul 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care, medication administration, infection control, food service, safety, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to document resident consent for wandering safety devices, inadequate dental care offerings, improper medication administration including a significant medication error, failure to maintain resident privacy during care, inadequate infection control practices, unsafe transfer practices, failure to maintain food temperatures, and environmental cleanliness issues.
Deficiencies (11)
Failure to provide supporting documentation for use of wandering safety device and resident consent for one resident.
Failure to ensure privacy during blood glucose testing and insulin administration for one resident.
Failure to notify residents or representatives in writing about bed hold policies upon hospital transfer for three residents.
Failure to aspirate or flush IV catheter prior to medication administration for one resident.
Failure to lock wheels on mobile devices prior to transferring and repositioning one resident.
Failure to monitor, clean, and assess ability to perform self-care of suprapubic catheter for one resident.
Significant medication error by administering incorrect antibiotic for three days to one resident.
Failure to offer and provide dental services for one resident without teeth.
Failure to maintain hot food temperatures on room trays for two residents and failure to maintain food safety and cleanliness in kitchen and dining areas.
Failure to implement infection prevention and control practices including hand hygiene and sterile technique during IV medication administration and resident care.
Failure to maintain clean, safe, and comfortable environment including dust buildup, unsecured vent screens, damaged commode seat, lack of negative air flow in shower rooms, and high temperatures in kitchenette.
Report Facts
Resident census: 80
BIMS score: 15
BIMS score: 13
BIMS score: 6
Temperature: 110.4
Temperature: 108.2
Temperature: 93.3
Temperature: 90.9
Urine volume: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered IV medication without flushing line; involved in medication error |
| CNA F | Certified Nursing Assistant | Failed to perform proper hand hygiene during resident care |
| CNA G | Certified Nursing Assistant | Failed to perform proper hand hygiene during resident care |
| Pharmacist A | Pharmacist | Notified facility of medication transcription error |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and facility practices |
| RN A | Registered Nurse | Provided interview on dental care and catheter care |
| CNA A | Certified Nursing Assistant | Provided interview on food temperature and catheter care |
| Assistant Director of Dining Services | Assistant Director | Provided interview on food service deficiencies |
| Maintenance Worker B | Maintenance Worker | Provided interview on environmental deficiencies |
Inspection Report
Routine
Census: 84
Deficiencies: 5
Date: Oct 29, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication management, and facility operations.
Findings
The facility was found deficient in coordinating hospice care for a resident, ensuring narcotic counts were properly completed and signed, documenting behaviors and non-pharmacological interventions prior to PRN anti-anxiety medication administration, preventing medication errors including crushing medications not approved for crushing and improper eye drop administration, and properly dating multi-dose medications including insulin pens and liquid narcotics.
Deficiencies (5)
Failed to ensure coordination of care with hospice services for one resident; no hospice book or coordinated care plan was maintained.
Failed to ensure narcotic counts were completed and signed by two staff each shift for medication carts and rooms, with multiple missed or improper signatures.
Failed to document behaviors and non-pharmacological interventions prior to administration of PRN anti-anxiety medication for one resident.
Medication errors including crushing medications not approved for crushing and failure to apply pressure to inner corner of eyes after eye drop administration for glaucoma.
Multi-dose medications including insulin pens and liquid narcotics were not dated when opened.
Report Facts
Facility census: 84
Medication error rate: 16.67
Narcotic count missed signatures: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Interviewed regarding hospice care coordination and narcotic counts |
| RN B | Registered Nurse, Unit Manager | Interviewed regarding hospice care coordination and narcotic counts |
| MDS Coordinator A | Mentioned in relation to hospice care plan monitoring | |
| Social Worker A | Social Worker | Interviewed regarding hospice care plan documentation |
| DON | Director of Nursing | Interviewed regarding hospice care, narcotic counts, PRN medication documentation, and medication dating |
| ADON | Assistant Director of Nursing | Interviewed regarding hospice care, narcotic counts, PRN medication documentation, and medication dating |
| LPN K | Licensed Practical Nurse | Observed crushing medications not approved for crushing and interviewed about medication crushing |
| LPN L | Licensed Practical Nurse | Observed administering eye drops without applying pressure and interviewed about eye drop administration |
| LPN G | Licensed Practical Nurse | Interviewed regarding narcotic counts and medication dating |
| LPN B | Licensed Practical Nurse | Interviewed regarding narcotic counts and medication dating |
Report
Jan 10, 2025
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Jan 9, 2025
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Jul 9, 2024
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Feb 6, 2024
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Jul 3, 2023
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Nov 29, 2022
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Nov 29, 2021
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Oct 29, 2021
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Dec 29, 2020
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Nov 13, 2020
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Aug 24, 2020
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Aug 4, 2020
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Jul 16, 2020
Report
May 22, 2020
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Oct 21, 2019
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Oct 21, 2019
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Oct 25, 2018
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Oct 25, 2018
Report
May 31, 2018
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