Inspection Reports for
Gasconade Manor Nursing Home
1910 NURSING HOME RD, OWENSVILLE, MO, 65066-2844
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
77% 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
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
Annual Inspection
Census: 61
Deficiencies: 4
Date: May 31, 2024
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations at Gasconade Manor Nursing Home.
Findings
The facility was found deficient in providing ongoing weekend activities for residents, posting nurse staffing information accessibly, maintaining medication error rates below 5%, and ensuring food safety standards related to dishwasher operation. Plans of correction were submitted addressing these deficiencies.
Deficiencies (4)
F679 Activities Meet Interest/Needs Each Resident. Facility staff failed to provide ongoing weekend activities for residents based on interviews and record review.
F732 Posted Nurse Staffing Information. Facility staff failed to post required nurse staffing information in an accessible location and include all required data.
F759 Free of Medication Error Rates 5 Percent or More. Facility failed to maintain medication error rates below 5%, with an 8% error rate observed affecting one resident.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. Facility failed to maintain dishwasher in good repair to ensure proper sanitization and temperature, risking cross-contamination.
Report Facts
Facility census: 61
Medication error rate: 8
Medication opportunities observed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician D | Certified Medication Technician | Named in medication administration observation and error finding |
| Director of Nursing | Director of Nursing | Interviewed regarding weekend activities and medication administration procedures |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed and observed regarding dishwasher operation and food safety |
| Cook F | Cook | Interviewed and observed regarding dishwasher operation and food preparation |
Inspection Report
Life Safety
Census: 61
Capacity: 79
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to test the freezing point of the antifreeze solution in the wet pipe sprinkler system annually as required, and failed to inspect and test the emergency generator according to NFPA standards. These deficiencies have the potential to affect all occupants in two smoke zones and the entire facility respectively.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing. The facility failed to test the freezing point of the antifreeze solution in the wet pipe sprinkler system annually as required by NFPA 25 standards.
K918 Electrical Systems - Essential Electric System Maintenance and Testing. The facility failed to inspect and test the emergency generator and transfer switches annually, including the required one and one-half hour load bank test, as required by NFPA 110 standards.
Report Facts
Facility census: 61
Total capacity: 79
Dates of generator load tests documented below 30% capacity: 25% on 05/29/23, 26% on 08/31/23, 28% on 04/30/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynette L. Biggs | Administrator | Signed the inspection report and plan of correction |
| Maintenance Director | Interviewed regarding sprinkler and generator maintenance and testing responsibilities | |
| Administrator | Interviewed regarding oversight of maintenance director and contracted service provider |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 12
Date: Feb 24, 2023
Visit Reason
Annual state survey conducted to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found noncompliant with multiple regulatory requirements including accounting and records of personal funds, required postings, resident rights to survey results, grievance procedures, abuse/neglect policies, ADL care, food safety, infection control, antibiotic stewardship, and COVID-19 vaccination policies. Deficiencies were documented with specific examples and corrective actions planned.
Deficiencies (12)
F568 Accounting and Records of Personal Funds. The facility failed to maintain a system assuring full and complete accounting of residents' personal funds and did not provide receipts for transactions for sampled residents.
F575 Required Postings. The facility failed to post the telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents and visitors.
F577 Right to Survey Results/Advocate Agency Info. The facility failed to ensure the most recent survey results were posted and accessible to residents and family members.
F585 Grievances. The facility failed to maintain evidence demonstrating the results of all grievances for at least three years and did not have a complete grievance policy.
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to follow its policy to ensure completion of Nurse Aide Registry checks for employees with prior abuse/neglect incidents.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide necessary personal hygiene care and timely responses to call lights for sampled residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to store food properly, maintain food safety standards, and ensure hair restraints were used by dietary staff.
F880 Infection Prevention & Control. The facility failed to establish an infection prevention program including proper cleaning of blood glucose meters and conducting an annual review.
F881 Antibiotic Stewardship Program. The facility failed to develop and implement an antibiotic stewardship program to monitor antibiotic use.
F882 Infection Preventionist Qualifications/Role. The facility failed to ensure the infection preventionist completed required training and specialized education.
F883 Influenza and Pneumococcal Immunizations. The facility failed to ensure residents received required immunizations and proper education regarding vaccines.
F888 COVID-19 Vaccination of Facility Staff. The facility failed to ensure all staff were fully vaccinated or had approved exemptions and did not maintain proper documentation.
Report Facts
Facility census: 60
Number of employees sampled for Nurse Aide Registry check: 10
Number of staff members: 107
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 |
Inspection Report
Life Safety
Census: 60
Capacity: 79
Deficiencies: 4
Date: Feb 24, 2023
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness policies under a waiver declared by the Secretary and to evaluate the facility's adherence to the Life Safety Code and fire safety regulations.
Findings
The facility failed to develop and implement emergency preparedness policies for care and treatment at alternate care sites under a waiver. Additionally, the facility did not maintain and test the fire alarm system, sprinkler system, and smoke barriers in accordance with applicable NFPA standards, posing potential risks to all occupants.
Deficiencies (4)
E026: Facility failed to develop policies and procedures for emergency preparedness under a waiver declared by the Secretary, risking delayed response in emergencies. The facility census was 60 with a capacity of 79.
K345: Facility staff failed to inspect and test the fire alarm system semi-annually and did not provide complete documentation for 100 percent inspection and testing. Records lacked policies for inspection, testing, and maintenance of the fire alarm system.
K353: Facility staff failed to maintain the dry pipe sprinkler system free of obstructions and did not provide complete documentation of sprinkler system installation and maintenance. Records lacked required information such as date of last sprinkler system check and water supply source.
K372: Facility staff failed to maintain seven of nine fire barrier walls free of openings and did not have policies for inspection and maintenance of fire barrier walls. Observations showed multiple unsealed holes and gaps in fire barrier walls.
Report Facts
Facility census: 60
Total capacity: 79
Number of manual pull stations: 21
Number of smoke detectors: 114
Number of heat detectors: 11
Number of waterflow switches: 3
Number of pressure switches: 4
Number of supervisory switches: 8
Number of horn notification appliances: 34
Number of strobe notification appliances: 45
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Date: Feb 27, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident with an injury of unknown origin. The facility was investigated for failure to properly investigate and report the injury.
Complaint Details
The complaint investigation was substantiated. The facility failed to investigate and report an injury of unknown origin for Resident #15 and failed to follow required policies and procedures related to abuse and neglect investigations.
Findings
The facility failed to investigate an injury of unknown origin for a resident and did not report the injury to the State Agency as required. Additionally, the facility failed to complete accurate comprehensive assessments and care plans for residents, including failure to document and update care plans related to injuries and medical conditions.
Deficiencies (4)
F610: The facility failed to investigate and report an injury of unknown origin for a resident as required by regulations.
F636: The facility failed to conduct accurate and timely comprehensive resident assessments and did not provide accurate documentation to support care plan decisions.
F657: The facility failed to develop and revise comprehensive care plans to address residents' needs, including a newly diagnosed shoulder dislocation and insulin use.
F658: The facility failed to provide services in accordance with professional standards, including failure to document neurological assessments after falls and obtain physician orders for CPAP use.
Report Facts
Facility census: 63
Facility census: 83
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 27, 2020
Visit Reason
This document is a plan of correction related to a state inspection of Gasconade Manor Nursing Home conducted on February 27, 2020.
Findings
The Emergency Preparedness portion of the survey did not result in deficiencies. The facility met the applicable provisions of the 2012 Life Safety Code. No state licensure deficiencies were cited as a result of this inspection.
Deficiencies (3)
42 CFR 483.73 The Emergency Preparedness portion of the survey did not result in deficiencies.
42 CFR 483.80 (a) The facility meets the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 4
Date: Jan 11, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Gasconade Manor Nursing Home following a survey completed on 01/11/2019. It addresses regulatory compliance issues identified during the inspection.
Findings
The facility failed to provide adequate written information regarding Medicaid/Medicare coverage and charges at admission, did not ensure proper admission policies including liability waivers, and failed to provide timely transfer/discharge notices. Deficiencies were also noted in infection prevention and control, including water management and tuberculosis testing policies.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide written explanation of items and services included or excluded in nursing facility services at admission, affecting Medicaid residents.
F620 Admissions Policy: The facility failed to establish and implement an admissions policy that complies with regulations, including not requiring residents to waive rights or facility liability, affecting all residents.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to ensure timely and proper notice of transfer or discharge to residents and their representatives, affecting all residents with initiated discharges or transfers.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including water management to prevent Legionella and proper tuberculosis testing for employees.
Report Facts
Medicaid residents affected: 29
Facility census: 53
Residents sampled for admission policy: 17
Residents sampled for transfer/discharge notice: 13
Inspection Report
Life Safety
Census: 53
Capacity: 79
Deficiencies: 2
Date: Jan 11, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related references.
Findings
The facility failed to maintain one fire suppression system in the rehabilitation wing kitchen in accordance with the 2012 Edition of NFPA 101, Life Safety Code. Specifically, a fryer was not covered by a nozzle connected to the fire suppression system, increasing the risk of fire development and exposure.
Deficiencies (2)
K324 Cooking Facilities: The facility failed to maintain one fire suppression system in the rehabilitation wing kitchen. A fryer was not covered by a nozzle connected to the fire suppression system as required by the 2012 Edition of NFPA 101.
A2017 Range Hood Certification: The facility did not provide a range hood and approved range hood extinguishing system that was installed, tested, and maintained in accordance with NFPA 96, 1998 edition. The range hood and extinguishing system were not certified at least twice annually.
Report Facts
Facility census: 53
Facility capacity: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Maintenance Director | Maintenance Director | Interviewed regarding the fire suppression system and fryer placement |
| Unknown Administrator | Administrator | Interviewed regarding fryer purchase and fire alarm inspections |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Aug 1, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify responsible parties of a resident's fall and significant change in condition.
Complaint Details
The complaint investigation found that staff did not notify the resident's emergency contact or physician after the resident was lowered to the floor, resulting in pain and bruising. Interviews with staff and family confirmed the failure to notify as required.
Findings
The facility failed to notify the resident's emergency contact and physician after a resident was lowered to the floor and developed pain and bruising. Staff did not follow the facility's policy for falls and significant change notifications.
Deficiencies (3)
F580 Notification of Changes: The facility failed to notify the resident's emergency contact and physician after the resident was lowered to the floor and developed pain and bruising on the right shoulder and arm.
F580 Admission to a composite distinct part: Facility staff failed to notify one resident's emergency contact and physician after a significant change in condition occurred.
A4087 Notify Responsible Party-Change in Condition: Facility staff did not immediately notify the person designated in the resident's record after a significant change in condition.
Report Facts
Facility census: 59
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 9, 2018
Visit Reason
Annual licensure inspection of Gasconade Manor Nursing Home to assess compliance with health care and state licensure requirements.
Findings
No health care deficiencies were cited. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 57
Capacity: 79
Deficiencies: 10
Date: Mar 9, 2018
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related references at Gasconade Manor Nursing Home.
Findings
The facility failed to meet several Life Safety Code requirements including emergency preparedness program deficiencies, access to all areas by staff, exit corridor obstructions, cooking facilities maintenance, fire alarm system out of service, sprinkler system impairment, and smoke barrier penetrations. The facility census was 57 with a capacity of 79.
Deficiencies (10)
E001: The facility failed to establish a complete and comprehensive emergency preparedness program meeting federal, state, and local requirements. Policies and procedures for tracking staff and residents, preservation and security of medical records, volunteer use, and emergency preparedness training were incomplete or missing.
K100: Facility staff failed to ensure access to all areas at all times, delaying emergency response. Maintenance Director and staff lacked knowledge of access requirements and door-locking arrangements.
K211: Facility failed to maintain exit corridors free of obstructions and unsecured furniture, including unsecured flower pots, tables, and chairs, and improperly mounted light fixtures.
K324: Facility failed to maintain two residential cooking facilities open to the corridor in accordance with NFPA 101, increasing fire risk. The range hood exhaust and fire suppression systems were incomplete or missing required features.
K346: Fire alarm system was out of service for more than four hours without complete written policies or interim safety measures. Fire watch procedures were incomplete.
K354: Sprinkler system was out of service for more than ten hours without complete policies for fire watch and interim safety measures.
K363: Facility failed to maintain fire doors with positive latching devices and proper clearance, allowing smoke passage and gaps exceeding code requirements.
K372: Smoke barrier penetrations were found with unsealed holes and unprotected wiring, compromising smoke containment.
K521: Facility failed to provide functioning exhaust ventilation units in public restrooms, affecting air quality and safety.
K918: Facility failed to maintain and test emergency generator and electrical systems per NFPA standards, including incomplete documentation and delayed repairs.
Report Facts
Facility census: 57
Total capacity: 79
Deficiency counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal L. Ray | Administrator | Signed the report as Laboratory Director or Provider/Supplier Representative |
Viewing
Loading inspection reports...
