Inspection Reports for
Good Shepherd Care Center
1101 WEST CLAY RD, VERSAILLES, MO, 65084-1177
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
43% occupied
Based on a February 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 2, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Good Shepherd Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 51
Deficiencies: 8
Date: Feb 16, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, neurological assessments post-falls, bed rail safety, food and nutrition services, food storage and sanitation, hand hygiene, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had access to their funds on weekends, incomplete neurological assessments after unwitnessed falls for cognitively impaired residents, inadequate entrapment assessments and consent for bed rail use, lack of qualified full-time dietary staff, improper food storage and labeling, poor hand hygiene practices among staff, unclean and poorly maintained kitchen floors, and ice machine drains lacking required air gaps.
Deficiencies (8)
Failed to ensure two residents had appropriate access to their trust fund account on weekends.
Failed to complete neurological assessments for four cognitively impaired residents after unwitnessed falls.
Failed to accurately complete entrapment assessments and obtain consent for bed rail use for five residents.
Failed to designate a qualified full-time Director of Food and Nutrition Services.
Failed to store food properly to prevent contamination and outdated use, including undated and expired items.
Failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination.
Failed to maintain kitchen floors clean and in good repair, with excessive debris and broken tiles.
Failed to ensure ice machine drains had required air gaps to prevent cross-contamination.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 5
Facility census: 51
Dented cans: 2
Expired food items: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON/Charge nurse | Provided information on neurological assessments and post-fall protocols |
| Director of Nursing | DON | Discussed bed rail assessments and entrapment assessment processes |
| Dietary Manager | DM | Discussed qualifications, food storage practices, and hand hygiene monitoring |
| Administrator | Provided expectations on post-fall assessments, hand hygiene, kitchen maintenance, and ice machine maintenance | |
| Assistant Maintenance Director | Discussed entrapment assessment responsibilities | |
| Maintenance Assistant | Discussed ice machine maintenance and lack of knowledge about air gap requirements | |
| Dietary Aide D | DA | Observed and interviewed regarding hand hygiene practices |
| Cook | Observed and interviewed regarding hand hygiene practices |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 5
Date: Nov 4, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident assessments, medication safety, mechanical lift transfers, nurse staffing postings, psychotropic medication use, and food storage and safety.
Findings
The facility was found deficient in timely electronic submission of quarterly Minimum Data Set assessments, safe medication storage and mechanical lift transfers, posting and retention of nurse staffing information, appropriate diagnosis for psychotropic medication use, and proper food storage and sanitation practices.
Deficiencies (5)
Failed to electronically transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for three residents.
Failed to provide safe mechanical lift transfers for four residents and failed to safely store medications by leaving medication cart unlocked and unattended.
Failed to post required nurse staffing information daily and failed to keep daily staffing records for eighteen months.
Failed to ensure medication regimens were free from unnecessary psychotropic medications due to lack of appropriate diagnoses for three residents.
Failed to store food properly to prevent contamination and out-dated use; failed to maintain food storage equipment clean and in good repair.
Report Facts
Residents affected: 3
Residents affected: 4
Residents affected: 61
Residents affected: 3
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Interviewed regarding medication cart lock issues and psychotropic medication appropriateness |
| CMT/CNA A | Certified Medication Aide/Certified Nurse Assistant | Interviewed about medication cart lock and nurse staffing postings |
| CMT/CNA C | Certified Medication Technician/Certified Nurse Assistant | Interviewed about medication cart lock and nurse staffing postings |
| RN G | Registered Nurse | Interviewed about medication cart lock and psychotropic medication appropriateness |
| DON | Director of Nursing | Interviewed about medication cart lock, mechanical lift procedures, psychotropic medication appropriateness, and nurse staffing postings |
| Administrator | Administrator | Interviewed about medication cart lock, nurse staffing postings, psychotropic medication appropriateness, and food storage issues |
| Maintenance Director | Maintenance Director | Interviewed about medication cart lock repair and maintenance requests |
| CNA J | Certified Nurse Assistant | Interviewed about mechanical lift use |
| NA L | Nurse Aide | Interviewed about mechanical lift use |
| CNA K | Certified Nurse Assistant | Observed and interviewed about mechanical lift use |
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