Inspection Reports for
Lakeview Health Care &Amp; Rehabilitation Center
1450 ASHLEY RD, BOONVILLE, MO, 65233-2141
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
253% occupied
Based on a July 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Jul 1, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report an allegation of physical abuse and failure to accurately transcribe a resident's medication order from the hospital.
Complaint Details
Complaint #1734617 involved allegations of physical abuse that were not reported timely and medication transcription errors. The investigation concluded the abuse allegation did not meet reporting requirements, but transcription errors posed a risk.
Findings
The facility failed to report an allegation of physical abuse within the required two-hour timeframe and failed to accurately transcribe a medication order for one resident, resulting in a risk of medication error. Both deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failed to timely report an allegation of physical abuse to the Department of Health and Senior Services within the two-hour timeframe.
Failed to accurately transcribe one resident's medication order from the hospital, resulting in incorrect medication administration instructions.
Report Facts
Residents affected: 1
Residents affected: 1
Facility census: 43
Medication order quantity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Completed investigation on abuse allegation and provided interview statements |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for ensuring accurate transcription of medication orders and provided interview statements |
| RN A | Registered Nurse | Interviewed regarding medication transcription error |
| Corporate nurse | Corporate Nurse | Interviewed regarding abuse investigation findings |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan development and revision requirements following resident falls, focusing on whether the facility reviewed and revised comprehensive care plans for residents who sustained falls.
Findings
The facility failed to review and revise the comprehensive care plans for two residents who sustained falls, despite policies requiring updates after each fall. Interviews with the MDS Coordinator and Director of Nursing revealed oversight in verifying that new interventions were added to care plans after falls.
Deficiencies (1)
Failure to review and revise comprehensive care plans for residents who sustained falls.
Report Facts
Residents affected: 2
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding care plan revisions and fall documentation | |
| Director of Nursing | DON | Interviewed regarding responsibility for ensuring care plan interventions were added |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to follow infection control practices and implement outbreak testing when two residents became symptomatic for COVID-19.
Complaint Details
The complaint investigation found that symptomatic residents were not tested for COVID-19 as required, with corporate office advising against testing despite physician orders and resident symptoms.
Findings
The facility staff failed to conduct timely COVID-19 testing for symptomatic residents despite policy directives and physician orders. Multiple residents showed symptoms consistent with COVID-19, but testing was delayed or not performed due to corporate office advisement.
Deficiencies (1)
Failure to follow infection control practices and implement outbreak testing when residents became symptomatic for COVID-19.
Report Facts
Residents affected: 2
Facility census: 48
Symptomatic residents: 11
Known positives: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported facility had four known positives and eleven symptomatic residents not tested due to corporate advisement | |
| Infection Preventionist | Stated staff should test symptomatic residents but asymptomatic residents are not tested per policy | |
| Registered Nurse B | Registered Nurse | Reported having standing orders from physician to test symptomatic residents and will follow physician orders |
Inspection Report
Routine
Census: 35
Deficiencies: 9
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with federal and state regulations related to resident care, staffing, safety, medication administration, infection control, and other operational standards at Lakeview Health Care & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to develop and update comprehensive person-centered care plans for residents, lack of weekend activities, unsafe storage of smoking materials for residents on oxygen, insufficient RN coverage on multiple days, incomplete daily nurse staffing postings, high medication error rate (50%), failure to prime insulin pens properly, lack of qualified dietary manager, and incomplete two-step TB testing for several employees. Deficiencies were generally cited at minimal or potential for minimal harm levels.
Deficiencies (9)
Failure to develop and implement comprehensive person-centered care plans and update them quarterly for sampled residents.
Failure to provide ongoing weekend activities to meet residents' interests.
Failure to ensure resident rooms were free of smoking materials for unsupervised smokers on oxygen.
Failure to provide RN coverage for at least 8 consecutive hours daily on multiple days.
Failure to post daily nurse staffing information including facility census on multiple days.
Medication error rate of 50% observed, including wrong dose and late administration of medications.
Failure to prime insulin pens before administration, risking underdosing.
Failure to employ a qualified dietary manager or ensure dietary manager had required qualifications.
Failure to complete two-step TB testing in accordance with policy for four employees.
Report Facts
Residents affected: 4
Medication error rate: 50
Facility census: 35
Days without RN coverage: 19
Missing daily staffing sheets: 15
Residents sampled: 12
Employees missing proper TB testing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to care plan deficiencies, RN coverage, medication errors, and TB testing |
| CMT C | Certified Medication Technician | Named in medication administration errors including wrong dose and late medication passes |
| RN D | Registered Nurse | Named in medication administration errors and RN coverage issues |
| Dietary B | Dietary Supervisor | Named in dietary manager qualification deficiency |
| LPN A | Licensed Practical Nurse | Named in TB testing deficiency |
Inspection Report
Routine
Census: 45
Deficiencies: 1
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to assess compliance with wound care protocols and pressure ulcer prevention standards following concerns about inadequate wound assessments and treatment for a resident with pressure injuries.
Findings
The facility failed to provide appropriate pressure ulcer care by not completing weekly wound assessments and failing to notify the physician when a resident's pressure injury worsened. Documentation was incomplete, and treatment orders were not consistently followed or updated, resulting in actual harm to a few residents.
Deficiencies (1)
Failure to complete weekly wound assessments for a resident with pressure injuries and failure to notify the physician of wound deterioration.
Report Facts
Residents affected: 3
Facility census: 45
Wound size: 2
Wound size: 1
Wound size: 0.3
Wound size: 3
Wound size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding wound care and documentation deficiencies |
| LPN B | Licensed Practical Nurse | Interviewed regarding wound assessment documentation and physician notification |
| Physician C | Physician | Interviewed regarding awareness and treatment of resident's wound |
Inspection Report
Routine
Census: 42
Deficiencies: 14
Date: Jun 27, 2023
Visit Reason
Routine inspection of Lakeview Health Care & Rehabilitation Center to assess compliance with regulatory requirements including resident safety, care planning, medication administration, environment, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to post required hotline information, maintain a clean and homelike environment, complete and update care plans, follow medication administration policies, ensure safe wheelchair propulsion, provide dialysis care documentation, complete bed rail assessments and consents, ensure nurse aide training compliance, maintain medication storage safety, keep kitchen and food storage sanitary, explain arbitration agreements properly, implement infection control procedures, and document influenza and pneumococcal vaccinations.
Deficiencies (14)
Failed to post required telephone number to the Department of Health and Senior Services hotline in an accessible manner.
Failed to ensure the most recent survey results were posted and accessible to residents and representatives.
Failed to maintain a clean, comfortable and homelike environment; odors of urine, body odor, cigarette smoke, and musty odors noted; maintenance issues such as broken blinds, missing screens, wall gouges, and peeling paint observed.
Failed to complete or update care plans and provide interventions to meet individual needs for three residents.
Failed to follow professional standards when staff prepared 26 medication cups prior to timed medication pass; failed to follow physician tube feeding orders and document food consumption for one resident.
Failed to ensure residents were propelled in wheelchairs with foot pedals to prevent accidents.
Failed to provide documentation of assessments, monitoring, and physician order for dialysis care for one resident.
Failed to complete side rail assessments, entrapment assessments, obtain physician orders, signed consents, and update care plans for six residents using side rails.
Failed to ensure two nurse aides completed nurse aide training program within four months of employment.
Failed to store medications safely and effectively; loose pills found in medication carts.
Failed to maintain kitchen equipment, walls, floors, and food storage in a clean and sanitary manner; freezer temperatures not consistently maintained at 0°F; unlabeled and undated food items observed.
Failed to ensure arbitration agreement was explained to resident or representative in a form and manner understood.
Failed to use appropriate infection control procedures during perineal care and failed to complete two-step TB testing for four employees.
Failed to offer, administer, and document influenza and pneumococcal immunizations or refusals for six residents.
Report Facts
Residents affected: 42
Medication cups prepared early: 26
Nurse Aides not certified within 4 months: 2
Loose pills found: 29
Residents sampled for vaccination documentation: 6
Employees missing second PPD test: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT M | Certified Medication Technician | Named in medication pre-population and medication cart maintenance findings |
| CNA H | Certified Nurse Aide | Named in perineal care infection control and odor management interviews |
| NA I | Nursing Assistant | Named in infection control observations |
| NA G | Nursing Assistant | Named in infection control observations |
| Administrator | Named in multiple interviews regarding facility policies and deficiencies | |
| Assistant Director of Nursing | Named in multiple interviews regarding care planning, medication, dialysis, infection control | |
| Director of Nursing | Named in odor management and care planning interviews | |
| Dietary Manager | Named in kitchen sanitation and food storage interviews | |
| Social Services Director | Named in arbitration agreement and TB testing interviews | |
| Business Office Manager | Named in nurse aide training compliance interviews |
Inspection Report
Routine
Census: 42
Deficiencies: 8
Date: Sep 24, 2021
Visit Reason
Routine inspection of Lakeview Health Care & Rehabilitation Center to assess compliance with regulatory requirements including resident care, safety, infection control, and facility management.
Findings
The facility was found deficient in multiple areas including insufficient surety bond coverage for resident funds, failure to notify physician of resident's refusal of BiPAP use, inadequate assistance with activities of daily living for several residents, inadequate fall prevention measures, failure to provide catheter care to prevent infections, improper behavioral health care including inappropriate use of antipsychotic medication without documented non-pharmacological interventions, incomplete water management program to prevent Legionella growth, and failure to properly assess, test, and isolate residents for COVID-19.
Deficiencies (8)
Facility staff failed to maintain a surety bond sufficient to ensure protection of resident funds.
Facility failed to notify resident's physician of refusal to wear ordered BiPAP.
Facility staff failed to provide assistance with activities of daily living for seven sampled residents.
Facility failed to provide adequate monitoring and interventions to ensure safety of residents at risk for falls and failed to monitor resident at risk for elopement.
Facility failed to provide catheter care to prevent catheter-associated urinary tract infections for one resident.
Facility failed to provide necessary behavioral health care and services including failure to implement non-pharmacological interventions before administering antipsychotic medication and administering Haldol to a resident without exhibited behaviors.
Facility failed to develop and implement complete water management policies and procedures to inhibit growth of waterborne pathogens and reduce risk of Legionnaire's Disease.
Facility failed to assess, test timely, and isolate a symptomatic resident for COVID-19, failed to identify a positive rapid COVID-19 test, and failed to separate a suspected positive resident from roommate.
Report Facts
Facility census: 42
Surety bond amount required: 52000
Surety bond amount held: 38000
Residents affected by ADL deficiency: 7
Residents affected by fall risk deficiency: 3
Residents affected by catheter care deficiency: 1
Residents affected by behavioral health deficiency: 2
Residents affected by COVID-19 testing deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician H | Physician | Expected staff to assist resident with BiPAP and to be notified if resident refused use |
| Licensed Practical Nurse A | LPN | Reported resident refused BiPAP and did not notify physician |
| Assistant Director of Nursing | ADON | Responsible for monitoring staff compliance with BiPAP use and behavioral health interventions |
| Director of Nursing | DON | Oversaw fall prevention, behavioral health, and COVID-19 testing procedures |
| Certified Nursing Assistant C | CNA | Reported resident coughs frequently and was unsure about COVID-19 testing |
| Maintenance Director | Maintenance Director | Responsible for water management program development and implementation |
| Administrator | Administrator | Responsible for oversight of water management program and COVID-19 testing/isolation |
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