Inspection Reports for
Good Shepherd Care Center
1101 WEST CLAY RD, VERSAILLES, MO, 65084-1177
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
12.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
124% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
41% occupied
Based on a May 2025 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 licensure inspection of Good Shepherd Care Center to assess compliance with health facility and state licensure requirements.
Findings
No health facility deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 49
Capacity: 120
Deficiencies: 3
Date: May 2, 2025
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 provide complete and verifiable documentation for the inspection, testing, and maintenance of the fire alarm system, fire drills, and electrical receptacles in resident care rooms. These deficiencies had the potential to affect all facility occupants.
Deficiencies (3)
K345 Fire Alarm System - Testing and Maintenance: The facility staff failed to inspect and test the fire alarm system semi-annually with complete and verifiable documentation as required by NFPA 72 standards.
K712 Fire Drills: The facility failed to provide complete and verifiable documentation of fire drills conducted quarterly on each shift under varying conditions, including simulated scenarios, as required by NFPA 101.
K914 Electrical Systems - Maintenance and Testing: The facility failed to provide complete and verifiable documentation for the assessment and testing of all electrical receptacles in resident care rooms in accordance with NFPA 99 requirements.
Report Facts
Facility census: 49
Total capacity: 120
Number of fire drills required annually: 12
Inspection Report
Life Safety
Census: 51
Capacity: 120
Deficiencies: 18
Date: Feb 16, 2024
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness policies at Good Shepherd Care Center.
Findings
The facility was found deficient in multiple areas including emergency preparedness plans, fire safety barriers, sprinkler systems, fire alarm systems, and hazardous area protections. Several fire safety systems were out of service or not maintained, and policies were incomplete or missing.
Deficiencies (18)
E013 Emergency preparedness policies and procedures were incomplete and did not address emerging infectious disease outbreaks. The facility failed to develop a comprehensive emergency preparedness plan.
E015 Policies for subsistence needs for staff and patients during emergencies were missing, including alternate energy sources and fire detection systems.
K000 The facility failed to meet provisions of the 2012 Life Safety Code related to building construction type and height.
K161 The facility failed to maintain the Type V wood-frame construction fire protection standard, including unsealed holes in ceilings and walls.
K321 Hazardous areas were not properly enclosed with self-closing, positive latching fire doors, risking smoke and fire spread.
K324 Cooking facilities had microwaves in resident sleeping rooms, violating fire safety policies.
K346 Fire alarm system was out of service for more than four hours without proper fire watch procedures in place.
K354 Sprinkler system was out of service for more than ten hours without adequate fire watch or notification procedures.
K372 Smoke barriers were not maintained properly, including failure to maintain fusible link dampers and documentation of inspections.
K916 Electrical systems lacked a remote annunciator panel for emergency power, and the facility failed to maintain emergency generator inspection records.
K923 Oxygen storage areas were not properly secured or separated from combustible materials, risking fire hazards.
A2008 Hazardous areas were not separated by at least one-hour fire-resistant construction or protected by automatic sprinkler systems.
A2010 Oxygen storage was not in compliance with NFPA 99 standards for permanent racks and separation from combustibles.
A2025 Fire alarm system was out of service for more than four hours without immediate notification and fire watch procedures.
A2054 Smoke section walls and doors were not properly fire rated or self-closing as required by code.
A2058 Fire drill and emergency preparedness plans were incomplete and lacked annual consultation and review.
A3001 The building was not substantially constructed or maintained in good repair as required by regulations.
A6015 Walls, ceilings, doors, windows, and skylights were not clean or maintained in good repair.
Report Facts
Facility census: 51
Total capacity: 120
Deficiencies cited: 17
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: 51
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for Good Shepherd Care Center.
Findings
The facility was found deficient in multiple areas including management of personal funds, professional standards of care, bedrails safety, dietary staffing qualifications, food safety, and hand hygiene practices. Several residents experienced unwitnessed falls without proper neurological assessments and monitoring.
Deficiencies (5)
F567 Protection/Management of Personal Funds. Facility failed to ensure two residents had appropriate access to their trust fund account on weekends and lacked a policy for availability of funds.
F658 Services Provided Meet Professional Standards. Facility staff failed to complete neurological assessments for four cognitively impaired residents after unwitnessed falls and lacked a post fall policy.
F700 Bedrails. Facility failed to provide a bed rail policy and did not complete entrapment assessments, bedrail assessments, or obtain consent for five residents using bed rails.
F801 Qualified Dietary Staff. Facility failed to employ a qualified dietitian or clinically qualified nutrition professional full-time and did not designate a director of food and nutrition services with appropriate qualifications.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. Facility failed to maintain proper food storage, labeling, sanitation, and hand hygiene practices in the dietary department.
Report Facts
Facility census: 51
Number of residents with bedrail deficiencies: 5
Number of residents with neurological assessment deficiencies: 4
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 |
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 10
Date: Nov 4, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Good Shepherd Care Center following a survey conducted on 11/04/2022.
Findings
The facility failed to electronically transmit quarterly Minimum Data Set assessments timely for three residents and failed to provide safe mechanical lift transfers and secure medication carts. Additionally, the facility failed to post nurse staffing information and ensure proper medication management and food safety practices.
Deficiencies (10)
F640 Encoding/Transmitting Resident Assessments. The facility failed to electronically transmit quarterly Minimum Data Set assessments for three residents within required timeframes.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to provide safe mechanical lift transfers for four residents and left medication carts unlocked and unattended.
F732 Posted Nurse Staffing Information. The facility failed to post required nurse staffing data daily and maintain staffing records for 18 months.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure appropriate use and documentation of psychotropic medications for residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food properly, maintain food storage equipment, and ensure food safety.
A4033 Employee Hours Documented. The facility failed to maintain written documentation of actual hours worked by each employee.
A4061 Drug Regimen Review-Monthly. The facility failed to ensure monthly pharmacist or nurse review of drug regimens with proper documentation.
A4074 Protective Oversight, Voluntary Leave. The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave.
A4108 Clinical Records - assessment/interventions. The facility failed to ensure clinical records contained sufficient information reflecting assessments and interventions.
A7015 Food-Protected, Temp, Need to Contact DHSS. The facility failed to protect food from contamination and maintain proper food temperatures.
Report Facts
Facility census: 61
Residents referenced: 3
Residents referenced: 4
Residents referenced: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide/Certified Nurse Assistant (CMT/CNA) A | Interviewed about medication cart usage and lock status | |
| Registered Nurse (RN) F | Interviewed about medication cart lock procedures and nurse staffing postings | |
| Certified Nurse Assistant (CNA) K | Observed assisting with mechanical lift transfers | |
| Nurse Aide (NA) L | Observed assisting with mechanical lift transfers and interviewed about lift procedures | |
| Director of Nursing (DON) | Interviewed about medication cart policies, nurse staffing postings, and psychotropic medication diagnoses | |
| Administrator | Interviewed about medication cart lock issues, nurse staffing postings, and kitchen management | |
| Maintenance Director | Interviewed about medication cart lock repairs and maintenance requests |
Inspection Report
Life Safety
Census: 61
Capacity: 120
Deficiencies: 7
Date: Nov 4, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Good Shepherd Care Center.
Findings
The facility failed to meet several life safety requirements including emergency lighting testing, fire alarm system inspection and testing, fire drills, smoking regulations, and door inspections. Deficiencies were noted in maintenance, documentation, and staff training related to fire safety.
Deficiencies (7)
K291 Emergency Lighting: Facility staff failed to conduct an annual 1.5-hour functional test of all emergency lighting equipment, risking equipment failure and delayed evacuation.
K345 Fire Alarm System: Staff failed to inspect and test the fire alarm system semi-annually and provide complete documentation, risking delayed emergency response.
K500 Building Services - Other: Facility failed to maintain lint-free gas dryer vents, increasing fire risk to all occupants.
K712 Fire Drills: Facility staff failed to conduct required fire drills quarterly under varied conditions, risking delayed response in a fire emergency.
K741 Smoking Regulations: Facility failed to maintain designated smoking areas free of fire hazards and proper disposal containers, risking fire hazards to occupants.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect and test fire doors annually and document results, risking compromised fire barriers.
K918 Electrical Systems - Essential Electric System: Facility failed to inspect, test, and maintain emergency generators and provide remote manual stop stations, risking power failure during emergencies.
Report Facts
Facility census: 61
Facility capacity: 120
Inspection Report
Routine
Deficiencies: 0
Date: Sep 8, 2021
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
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: 1
Date: Jul 20, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of physical abuse by a Certified Nursing Assistant (CNA) against a resident.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing physical abuse by CNA C against Resident #1. The CNA was suspended on 7/10/21 and terminated on 7/12/21.
Findings
The facility failed to ensure a resident was free from physical abuse when a staff member slapped the resident's arm during care. The CNA involved was suspended and later terminated following the investigation.
Deficiencies (1)
CFR 483.12(a)(1) Freedom from Abuse: The facility failed to prevent physical abuse when a staff member slapped a resident's arm during care.
Report Facts
Facility census: 63
Inspection Report
Routine
Deficiencies: 0
Date: Dec 11, 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 federal 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
Plan of Correction
Census: 73
Deficiencies: 1
Date: Sep 1, 2020
Visit Reason
The document is a plan of correction related to a deficiency in freedom from abuse and neglect at Good Shepherd Care Center, following a past non-compliance incident.
Findings
The facility failed to ensure one resident was free from physical abuse when a staff member hit the resident on the forehead causing a bruise. The facility conducted an investigation, suspended and terminated the responsible employee, and reviewed abuse and neglect policies with staff.
Deficiencies (1)
F 600: The facility failed to prevent physical abuse when a staff member hit a resident on the forehead causing a bruise. The facility took corrective actions including staff suspension, termination, and policy review.
Report Facts
Facility census: 73
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Plan of Correction
Census: 76
Capacity: 117
Deficiencies: 19
Date: Sep 27, 2019
Visit Reason
The document is a Plan of Correction related to a Life Safety Code inspection conducted at Good Shepherd Care Center on 09/27/2019.
Findings
The facility failed to meet several Life Safety Code requirements including emergency lighting testing, hazardous area door self-closing and latching, fire alarm system testing and maintenance, sprinkler system maintenance, corridor door integrity, smoke barrier maintenance, fire drill compliance, and electrical system maintenance. The facility census was 76 with a capacity of 117.
Deficiencies (19)
K291 Emergency Lighting: Facility staff failed to conduct an annual 1.5-hour functional test of all emergency lighting fixtures as required by NFPA 101.
K321 Hazardous Areas - Enclosure: Facility staff failed to ensure doors to hazardous areas were self-closing, positively latched, and maintained to prevent smoke passage.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to provide and maintain complete documentation of fire alarm system inspections and testing as required by NFPA 72.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain and document monthly inspections and testing of the sprinkler system in accordance with NFPA 25.
K363 Corridor Doors: Facility staff failed to ensure corridor doors were solid, resisted smoke passage, and were positively latched, compromising fire containment.
K372 Subdivision of Building Spaces - Smoke Barrier: Facility staff failed to maintain smoke barrier walls free of openings and properly inspect and repair smoke barrier doors.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Facility staff failed to maintain smoke barrier doors self-closing, latching, and free of penetrations as required.
K712 Fire Drills: Facility failed to conduct fire drills quarterly on each shift and maintain documentation as required by NFPA 101.
K761 Maintenance, Inspection & Testing - Doors: Facility failed to inspect, test, and maintain doors annually and document inspections as required.
K918 Electrical Systems - Essential Electric System: Facility failed to inspect, test, and maintain the emergency generator and document inspections as required by NFPA 110.
A1088 Door No Louvre/Transom, Solid-Core Wood/Metal: Doors between rooms and corridors lacked required louvers or transoms and did not meet fire resistance requirements.
A2008 Hazardous Areas: Hazardous areas were not properly separated by fire-resistant construction and doors were not self-closing or automatic closing.
A2019 Fire Alarm System-Test/Maintain: Facility failed to test and maintain the fire alarm system in accordance with NFPA 72 requirements.
A2034 Sprinkler System-Test/Maintain: Facility failed to maintain and test the sprinkler system as required by NFPA 25 standards.
A2050 Emergency Lighting: Facility failed to provide emergency lighting with sufficient intensity and failed to conduct required testing.
A2054 Smoke Section Walls/Doors: Smoke sections were not properly separated by fire-rated walls and doors were not self-closing or automatic closing.
A2061 Fire Drill Requirements, Evacuation: Facility failed to conduct required fire drills quarterly and maintain documentation.
A3001 Substantially Constructed/Maintained: Facility failed to maintain building in good repair and comply with construction standards.
A6040 Outside Openings Protected Against Rodents: Facility failed to effectively protect outside openings against rodents and maintain window screens.
Report Facts
Facility census: 76
Total capacity: 117
Deficiencies cited: 17
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 3
Date: Dec 7, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to psychotropic medication use, medication error rates, infection prevention and control, and other care standards at Good Shepherd Care Center.
Findings
The facility was found deficient in ensuring psychotropic medications had appropriate stop dates, maintaining medication error rates below 5%, and implementing an effective infection prevention and control program including water management and glucometer sanitation. Several residents' medication orders lacked clinical rationale for extending beyond 14 days, and staff failed to follow proper insulin administration and infection control procedures.
Deficiencies (3)
F758 Psychotropic Drugs: Facility staff failed to obtain stop dates of 14 days or less on PRN psychotropic medications for sampled residents, and did not document clinical rationale for extending orders beyond 14 days.
F759 Medication Errors: Facility staff failed to maintain medication error rates below 5%, with a 19% error rate observed affecting five sampled residents during insulin administration.
F880 Infection Prevention & Control: Facility failed to develop and implement policies and procedures for water management to prevent Legionella growth, and failed to properly sanitize glucometers and provide perineal care to prevent infection spread.
Report Facts
Facility census: 83
Medication error opportunities observed: 27
Medication errors observed: 5
Medication error rate: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in interview regarding PRN medication stop dates and insulin pen priming |
| RN, DNP | Clinical Nurse Educator | Provided training on insulin administration as part of plan of correction |
Inspection Report
Life Safety
Census: 83
Capacity: 120
Deficiencies: 4
Date: Dec 7, 2018
Visit Reason
Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness at Good Shepherd Care Center.
Findings
The facility failed to maintain four smoke barriers with proper fire resistance rating and failed to conduct fire drills under varying fire conditions as required. Deficiencies were noted in smoke barrier construction and fire drill execution.
Deficiencies (4)
K372: The facility failed to maintain four smoke barriers with at least a one and a half hour fire resistance rating, allowing potential smoke containment failure. Observations included improper sealant around sprinkler piping in smoke barriers.
K712: Facility staff failed to conduct fire drills under varying fire conditions from December 2017 through November 2018, risking delayed response in an actual fire emergency.
A2054: Smoke section walls and doors were not properly separated by one-hour fire-rated walls and doors, violating fire safety regulations.
A2061: Fire drill requirements for evacuation were not met, including conducting at least twelve drills annually with proper notification and resident involvement.
Report Facts
Facility census: 83
Total capacity: 120
Fire drills required annually: 12
Fire drills reviewed: 12
Fire drills lacking varying conditions: 7
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Nov 7, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident rights and smoking privileges at Good Shepherd Care Center.
Complaint Details
The complaint was substantiated as the facility restricted a resident's smoking privileges without proper procedures and supervision, violating resident rights.
Findings
The facility failed to ensure that residents were allowed to make choices about aspects of their lives, specifically restricting a resident's right to smoke as a consequence for behaviors. The resident's smoking privileges were revoked for two weeks without proper support or supervision.
Deficiencies (2)
F550 Resident Rights/Exercise of Rights was not met as the facility staff failed to allow a resident to exercise his right to smoke, revoking smoking privileges for two weeks without proper supervision or support.
A8042 Resident Lives Not Regulated/Controlled was not met as residents' personal lives were controlled beyond reasonable adherence to policies, specifically regarding smoking privileges.
Report Facts
Facility census: 88
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