Inspection Reports for
Gasconade Manor Nursing Home
1910 NURSING HOME RD, OWENSVILLE, MO, 65066-2844
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 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
61 residents
Based on a July 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 61
Deficiencies: 5
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including employee background checks, resident bed hold policies, medication labeling, infection control practices, and bed safety inspections.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly Employee Disqualification List checks for staff, failure to provide bed hold policy information to residents upon hospital transfer, failure to date multi-dose medications when opened, inadequate infection prevention and control practices including improper use of Enhanced Barrier Precautions, and failure to regularly inspect bedrails and reassess entrapment zones for residents using bed canes.
Deficiencies (5)
Failure to implement quarterly Employee Disqualification List checks for six staff members.
Failure to provide written bed hold policy information to residents or their representatives upon hospital transfer for three residents.
Failure to date multi-dose medications when opened in one of two medication storage carts.
Failure to use Enhanced Barrier Precautions including gowns, gloves, and proper hand hygiene during catheter care, wound care, and mechanical transfers for multiple residents.
Failure to conduct regular inspections of bedrails and reassess entrapment zones for residents using bed canes; entrapment measurements were only completed upon admission and not updated regularly.
Report Facts
Facility census: 61
Staff sampled for EDL checks: 10
Residents sampled for bed hold policy: 17
Residents sampled for infection control: 18
Residents sampled for bedrail inspection: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Named in findings related to failure to date medications and improper infection control practices |
| CNA J | Certified Nurse Assistant | Named in findings related to improper infection control practices |
| CMT K | Certified Medication Technician | Named in findings related to infection control and PPE stocking |
| ADON | Assistant Director of Nursing | Named in multiple interviews regarding infection control and PPE compliance |
| Administrator | Named in multiple interviews regarding facility policies and oversight responsibilities | |
| Human Resources | Named in findings related to failure to conduct quarterly Employee Disqualification List checks | |
| CNA C | Certified Nurse Assistant | Named in infection control observations and interviews |
| CNA B | Certified Nurse Assistant | Named in infection control observations and interviews |
| CMT D | Certified Medication Technician | Named in infection control observations and interviews |
| CNA Q | Certified Nurse Assistant | Named in infection control observations |
| Maintenance Director | Named in findings related to bedrail entrapment measurements |
Inspection Report
Routine
Census: 61
Deficiencies: 5
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident activities, nurse staffing postings, medication administration, food safety, and facility operations.
Findings
The facility failed to provide scheduled weekend activities for residents, did not post nurse staffing information in an accessible manner or with required data, had a medication error rate exceeding 5% due to insulin pen priming errors, and failed to maintain the mechanical dishwasher at required temperatures, risking cross-contamination. Additional food storage and sanitation issues were also noted.
Deficiencies (5)
Failed to provide an ongoing program of activities designed to meet residents' interests on weekends for two sampled residents.
Failed to post required nurse staffing information in an easily accessible place and failed to include required data in the posting.
Failed to ensure medication error rates were less than 5%; two insulin administration errors occurred due to failure to prime insulin pen.
Failed to maintain mechanical dishwasher at minimum required temperature of 120°F, risking ineffective sanitization and cross-contamination.
Food storage issues including undated open packages, uncovered raw produce stored above ready-to-eat foods, and food debris on cooler floor.
Report Facts
Facility census: 61
Medication error rate: 8
Medication administration opportunities observed: 25
Medication errors observed: 2
Dishwasher wash cycle temperature: 110
Dishwasher rinse cycle temperature: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician C | Certified Medication Technician | Administered insulin without priming the insulin pen |
| Certified Medication Technician A | Certified Medication Technician | Administered insulin without priming the insulin pen and acknowledged the error |
| Director of Nursing | Director of Nursing | Provided information on insulin pen priming, nurse staffing posting responsibilities, and weekend activities |
| Certified Dietary Manager | Certified Dietary Manager | Observed washing dishes in dishwasher not reaching required temperature and provided related interview statements |
| Administrator | Administrator | Provided information on weekend activities and nurse staffing posting requirements |
Inspection Report
Routine
Census: 60
Deficiencies: 12
Date: Feb 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident funds management, posting of hotline information, grievance handling, staff background checks, resident care, food safety, infection control, antibiotic stewardship, immunizations, and staff COVID-19 vaccination status.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate accounting of resident funds, failure to post required hotline information accessibly, inadequate grievance documentation, incomplete nurse aide registry checks for staff, failure to provide adequate personal care and timely call light response, improper food storage and labeling, failure to wear hair restraints in dietary services, inadequate cleaning of blood glucose meters between residents, lack of a comprehensive antibiotic stewardship program, incomplete infection preventionist training, failure to follow pneumococcal and influenza vaccination guidelines, and incomplete staff COVID-19 vaccination or exemption documentation.
Deficiencies (12)
Failed to maintain a system assuring full and complete accounting of each resident's personal funds, including lack of receipts and descriptions for transactions.
Failed to post the telephone number for the Adult Abuse and Neglect Hotline in an accessible location on the rehabilitation unit.
Failed to ensure the most recent survey results were posted and accessible to residents and families.
Failed to maintain evidence demonstrating results of grievances for at least three years and failed to provide written responses to resident grievances.
Failed to complete required Nurse Aide Registry checks prior to employment for 10 sampled employees.
Failed to provide necessary care and services to maintain good personal hygiene for residents unable to perform ADLs and failed to answer call lights timely.
Failed to store food properly to prevent contamination and out-dated use, failed to use first in-first out method, and failed to wear hair restraints in dietary services.
Failed to maintain clean blood glucose meters between residents, risking transmission of infection.
Failed to develop and implement an antibiotic stewardship program with appropriate tracking and reporting.
Failed to ensure infection preventionist completed required specialized training prior to assuming role.
Failed to maintain and follow current guidance for pneumococcal and influenza vaccinations for residents and failed to offer flu vaccine to one resident.
Failed to ensure 100% of staff were fully vaccinated for COVID-19 or had approved exemptions or delays.
Report Facts
Facility census: 60
Number of sampled employees without NA Registry check: 10
Call light response times (minutes): Array
Number of residents affected by personal funds deficiency: 2
Number of residents affected by hygiene and call light deficiencies: 4
Number of residents affected by infection control deficiency: 3
Number of staff not fully vaccinated for COVID-19: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT J | Certified Medication Technician | Named in infection control deficiency for improper cleaning of blood glucose meter |
| CNA J | Certified Nurse Assistant | Named in COVID-19 vaccination deficiency |
| CNA T | Certified Nurse Assistant | Named in COVID-19 vaccination deficiency |
| Employee U | Named in COVID-19 vaccination deficiency with incomplete medical exemption | |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control, antibiotic stewardship, immunizations, and COVID-19 vaccination |
| Assistant Administrator | Assistant Administrator | Interviewed regarding multiple deficiencies including infection control, antibiotic stewardship, immunizations, and COVID-19 vaccination |
| Infection Preventionist | Infection Preventionist | Named in antibiotic stewardship and infection preventionist training deficiencies |
| Certified Dietary Manager | Certified Dietary Manager | Named in food storage and hair restraint deficiencies |
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