Inspection Reports for
Laverna Manor Health & Rehabilitation
904 SOUTH HALL AVE, SAVANNAH, MO, 64485-1952
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
107% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
46% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: Dec 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding missing fentanyl patches for two residents and a fall incident involving a mechanical lift causing injury to another resident.
Complaint Details
The investigation was triggered by complaints about missing fentanyl patches for Residents #2 and #3, and a fall incident involving Resident #1 from a mechanical lift. The patches were unaccounted for and no proper investigation was conducted. Resident #1 was not sent to the hospital as ordered after the fall, and the resident fell due to improper sling attachment during transfer.
Findings
The facility failed to ensure proper investigation and accounting for missing fentanyl patches for two residents, and failed to follow physician orders to send a resident to the hospital after a fall from a mechanical lift. Additionally, the facility failed to ensure safe transfer procedures, resulting in a resident falling from a mechanical lift causing pain and injury.
Deficiencies (3)
Failed to ensure residents were free from misappropriation of fentanyl patches and failed to conduct proper investigations for missing patches.
Failed to follow physician's orders to send a resident to the hospital for x-rays after a fall from a mechanical lift.
Failed to properly transfer a resident using a mechanical lift, resulting in the resident falling and sustaining pain to shoulders and left hip.
Report Facts
Facility census: 55
Fentanyl patch dosage: 12
Fall height: 4
Hydrocodone-Acetaminophen dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Reported missing fentanyl patch for Resident #2 and assessed Resident #1 after fall |
| Director of Nursing | Director of Nursing (DON) | Notified of missing fentanyl patches and fall incident; did not conduct investigation |
| Primary Care Physician A | Primary Care Physician | Ordered hospital evaluation after Resident #1 fall; disagreed with facility decision to use mobile x-rays |
| Administrator | Facility Administrator | Informed staff to use mobile x-rays instead of hospital for Resident #1; expected investigations for missing patches |
| CNA A | Certified Nurse Aide | Assisted in transfer of Resident #1 during fall incident |
| CNA B | Certified Nurse Aide | Assisted in transfer of Resident #1 during fall incident |
| Medical Director | Medical Director | Expected notification of missing narcotics and adherence to physician orders |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the misappropriation of a resident's narcotic medications at the facility.
Complaint Details
The complaint investigation found no allegation as to why the investigation was prompted, no alleged perpetrator identified, and local police were contacted. The investigation revealed lack of proper inventory controls and that the missing drugs were most likely taken by a staff member.
Findings
The facility failed to ensure one resident was free from misappropriation of narcotic medications, with approximately 60 pills of Oxycodone 5mg missing. The investigation was inconclusive, with no perpetrator identified, and revealed inadequate inventory controls over controlled substances.
Deficiencies (1)
Failure to protect a resident from misappropriation of narcotic medications.
Report Facts
Residents affected: 1
Census: 58
Missing medication count: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding medication counts and narcotic inventory procedures |
| Administrator | Facility Administrator | Interviewed regarding previous and current medication inventory processes |
| Police Officer A | Police Officer | Conducted preliminary investigation and stated evidence indicated staff involvement |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: May 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a sexual abuse incident where one resident (Resident #2) inappropriately touched another resident (Resident #1) in the memory care unit.
Complaint Details
The complaint investigation was substantiated. The incident occurred on 4/14/25 when Resident #2 ran his/her hand up Resident #1's thighs and grabbed the genital area. Both residents had severely impaired cognition and could not provide information. The facility took immediate corrective actions including 1:1 supervision and medication adjustments.
Findings
The facility failed to keep Resident #1 safe from sexual abuse by Resident #2. Upon discovery, the facility immediately separated the residents, assessed them with no injuries found, placed Resident #2 on 1:1 supervision, initiated abuse training for staff, and adjusted Resident #2's medications. The noncompliance was corrected within three days.
Deficiencies (1)
Failure to protect a resident from sexual abuse by another resident.
Report Facts
Residents present: 61
Date of incident: Apr 14, 2025
Date noncompliance corrected: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Observed the abuse incident and notified charge nurse |
| Director of Nursing | Interviewed regarding immediate actions taken after the incident | |
| Administrator | Interviewed regarding follow-up actions and family communication |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of physical abuse where one resident (R23) hit another resident (R42) unprovoked on 09/28/2024.
Complaint Details
The complaint was substantiated. The incident occurred on 09/28/24 when R23 hit R42 on the shoulder without provocation. Interviews with staff and residents confirmed the event. R23 was placed on 1:1 supervision and discharged for psychiatric evaluation.
Findings
The facility failed to protect a resident's right to be free from physical abuse when R23 hit R42 on the shoulder. The allegation was substantiated after investigation, and R23 was placed on 1:1 supervision until discharged for psychiatric evaluation.
Deficiencies (1)
Failure to protect residents from physical abuse when R23 hit R42 unprovoked.
Report Facts
Facility census: 57
BIMS score: 7
BIMS score: 1
Residents reviewed for abuse: 4
Sample residents: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide 1 | Hospitality Aide | Reported the incident and provided details about the event on 09/28/24 |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Assessed residents after the incident but did not document assessment; notified Director of Nursing |
| Director of Nursing | Director of Nursing | Was notified about the incident but was out of town; Administrator handled investigation |
| Administrator | Administrator | Handled the investigation, substantiated the allegation, and placed R23 on 1:1 supervision |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 5
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect a resident from physical abuse by another resident, failure to provide timely written transfer/discharge notices, failure to provide written bed hold notices, failure to complete quarterly Minimum Data Set (MDS) assessments, and failure to ensure accurate MDS assessments.
Complaint Details
The complaint investigation was substantiated. Resident R23, with a history of hitting another resident, hit resident R42 unprovoked on 09/28/24. The facility confirmed the incident and placed R23 on 1:1 supervision until psychiatric evaluation and discharge.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to provide written transfer/discharge and bed hold notices to residents transferred to the hospital, failed to complete and submit a quarterly MDS assessment for one resident, and failed to ensure accurate MDS assessments for five residents. The abuse allegation was substantiated and the facility census was 57.
Deficiencies (5)
Failed to protect resident R42 from physical abuse by resident R23.
Failed to provide timely written transfer/discharge notices to residents R29 and R61.
Failed to provide written bed hold notices to residents R29 and R61.
Failed to complete and submit quarterly MDS assessment for resident R14.
Failed to ensure accurate MDS assessments for residents R37, R29, R30, R34, and R57 due to incorrect coding of medications and tobacco use.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 5
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide 1 | Hospitality Aide | Witnessed and reported the abuse incident between residents R23 and R42 |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Assessed residents after abuse incident but failed to document assessment |
| Director of Nursing | Director of Nursing | Was notified of abuse incident but was out of town; confirmed use of RAI Manual for assessments |
| Administrator | Administrator | Handled investigation of abuse incident and confirmed substantiation |
| RN1 | Registered Nurse | Described emergent transfer process and provision of notices |
| Social Services Director | Social Services Director | Reviewed transfer and bed hold notices and confirmed lack of documentation |
| MDS Coordinator | MDS Coordinator | Acknowledged missed submission of quarterly MDS and inaccurate coding of medications |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of a cognitively impaired resident with a known elopement risk, who eloped twice resulting in injury.
Complaint Details
The visit was complaint-related due to allegations of inadequate supervision of a resident at risk for elopement. The complaint was substantiated as the resident eloped twice, sustained injuries, and the facility failed to maintain required supervision and secure windows.
Findings
The facility failed to provide adequate supervision to Resident #1, who eloped twice through unsecured windows, resulting in serious injuries including fractures. The facility did not maintain one-on-one supervision as ordered and failed to secure the resident's bedroom window promptly. Maintenance secured only the dining room windows initially. The resident sustained fractures to both heels and lumbar spine and was subsequently bed bound.
Deficiencies (1)
Failure to provide adequate supervision to a cognitively impaired resident with elopement risk, resulting in elopement and injury.
Report Facts
Resident census: 58
Elopement risk score: 18
Fall risk score: 8
Window height: 6
Window height: 13.5
Skin tear size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Notified Director of Nursing of immediate jeopardy and assessed resident after elopement |
| CNA C | Certified Nurse Aide | Assigned to one-on-one supervision of resident after first elopement |
| DON | Director of Nursing | Notified of elopements, instructed staff on supervision and window security |
| Maintenance | Secured dining room windows after first elopement and bedroom window after second elopement | |
| LPN A | Licensed Practical Nurse | Found resident after second elopement and called emergency responders |
| CNA E | Certified Nurse Aide | Performed 15-minute checks on resident and found resident after second elopement |
| CMT A | Certified Medication Technician | Worked with resident and observed exit seeking behavior |
| CMT C | Certified Medication Technician | Observed resident behaviors and assisted after second elopement |
| CNA B | Certified Nurse Aide | Observed resident elopement and notified staff |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 3
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional and food safety standards, including menu preparation, food palatability, temperature control, and food service safety.
Findings
The facility failed to ensure menus were prepared in advance and posted, residents were not offered menu choices, food was not served at safe and appetizing temperatures, and food service safety standards were not met, including failure to maintain proper food temperatures and sanitation practices during food distribution.
Deficiencies (3)
Menus were not prepared in advance, not posted, residents not offered menu choices, and alternatives not posted.
Food served was not palatable, attractive, or at a safe and appetizing temperature; meat was too hard to cut; condiments not offered.
Failed to maintain food temperatures during distribution, did not temperature check foods after reheating, failed to cover foods during transport, reused meal trays improperly, and failed to check dishwashing temperatures.
Report Facts
Residents affected: 3
Residents affected: 5
Census: 58
Inspection Report
Routine
Census: 74
Deficiencies: 6
Date: Mar 25, 2024
Visit Reason
The inspection was conducted to assess compliance with resident dignity and respect, menu preparation and choice, food palatability and temperature, and food safety standards at the facility.
Findings
The facility failed to ensure residents were treated with dignity during meal service by using plastic cutlery and Styrofoam plates for an extended period. Menus were not prepared or posted in advance, limiting resident choice. Food was often served cold or at unsafe temperatures, and condiments were not consistently offered. Food safety practices were deficient, including failure to maintain proper food temperatures during transport and service, reuse of un-sanitized trays, and incomplete dishwasher temperature logs.
Deficiencies (6)
Failure to provide dignified dining experience using appropriate dishware and utensils.
Menus were not prepared in advance, not posted, and alternatives were not offered or posted.
Food served was not palatable, attractive, or at safe and appetizing temperatures; condiments not offered as appropriate.
Failure to maintain food temperatures during distribution and service; food temperatures below safe levels.
Reuse of un-sanitized meal trays for serving multiple residents, risking cross contamination.
Dishwasher temperature logs were incomplete and not consistently recorded as required.
Report Facts
Facility census: 74
Facility census: 58
Food temperature: 120
Food temperature: 117.1
Food temperature: 110.7
Dishwasher temperature: 189
Dishwasher temperature log frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Provided multiple interviews regarding food temperatures, menu posting, and food service practices | |
| Certified Nurse Aide (CNA) A | Interviewed regarding meal service, food temperature complaints, and tray handling | |
| Certified Nurse Aide (CNA) B | Interviewed regarding meal service, food temperature complaints, and tray handling | |
| Certified Nurse Aide (CNA) C | Interviewed regarding meal ticket system and food service practices | |
| Administrator | Interviewed regarding dishwasher use, food temperature expectations, and resident complaints | |
| Dietary Aide [NAME] A | Observed transporting food carts and serving meals; involved in incidents of dropped meal tickets and tray reuse |
Inspection Report
Census: 60
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection was conducted to assess compliance with resident nutritional needs, specifically regarding the provision of meals and snacks according to resident preferences and requests.
Findings
The facility failed to provide night time snacks according to resident preferences, affecting three sampled residents. Interviews and record reviews revealed that snacks had not been consistently offered for two to four months, with limited snack options and budget constraints cited as contributing factors.
Deficiencies (1)
Failure to honor resident choices by not offering night time snacks according to preferences.
Report Facts
Residents affected: 3
Facility census: 60
Duration of issue: 3
Inspection Report
Routine
Census: 62
Deficiencies: 4
Date: Mar 14, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with physician orders regarding weekly weights and nutritional interventions for residents, specifically addressing concerns about unplanned weight loss in several residents.
Findings
The facility failed to ensure weekly weights were obtained and interventions implemented for three of four residents to maintain nutritional status and prevent significant weight loss. The facility lacked a policy on nutrition and unplanned weight loss, and care plans did not adequately address weight loss risks or interventions. Staff and administration were unaware of some residents' weight loss issues.
Deficiencies (4)
Failure to follow physician's orders to obtain weekly weights and implement interventions for residents to maintain nutritional status and prevent significant weight loss.
Facility did not provide a policy on nutrition and/or unplanned weight loss.
Care plans lacked interventions addressing residents' current weight loss or risk for weight changes.
Staff and administration were not aware of residents with weight loss and did not consistently notify appropriate personnel or update care plans accordingly.
Report Facts
Weight loss: 13
Weight loss: 13.7
Weight loss: 7.2
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding weighing procedures and notification process for weight changes. |
| ADN | Assistant Director of Nursing | Interviewed about monitoring resident weights and notification of physicians for weight loss. |
| MDS coordinator | Responsible for care planning weight loss and nutrition interventions; interviewed about awareness of residents' weight loss. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about notification and care planning for residents with weight loss. |
| Administrator | Administrator | Interviewed about notification and plans for residents with weight loss. |
Inspection Report
Routine
Census: 59
Deficiencies: 20
Date: Aug 25, 2022
Visit Reason
Routine inspection of Laverna Manor Health & Rehabilitation to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication management, infection control, staffing, activities programming, food safety, pressure ulcer care, and quality assurance processes. Specific issues included failure to provide adequate personal care and activities, medication errors, expired and unlabeled medications, lack of RN coverage, inadequate infection preventionist designation, and failure to maintain a clean kitchen environment.
Deficiencies (20)
Failure to treat residents with dignity and respect, including inadequate personal hygiene, grooming, and resident rights.
Failure to properly manage resident trust funds, including failure to refund balances timely and maintain appropriate bonds.
Failure to provide required notices for Medicare non-coverage to residents discharged from skilled nursing services.
Use of physical restraints without proper documentation and inappropriate use of four-point restraints to hold a resident during care.
Failure to provide timely transfer/discharge notifications and bed-hold notices to residents and responsible parties.
Failure to follow professional standards in medication administration including lack of orders for blood sugar checks, improper insulin injection technique, and improper administration of eye and nasal sprays.
Failure to provide adequate personal care including incomplete perineal care and inconsistent showering.
Failure to provide safe and appropriate respiratory care including lack of oxygen orders and failure to clean oxygen equipment.
Failure to maintain RN coverage for at least eight consecutive hours per day, seven days a week.
Employment of nurse aides under 18 years old and failure to ensure nurse aides complete required training within 120 days.
Failure to provide necessary behavioral health care and services to a resident with dementia and behavioral disturbances.
Failure to ensure monthly pharmacy drug regimen reviews for residents.
Medication error rate of 20% due to improper insulin administration and other medication errors.
Failure to properly label and discard expired medications and biologicals, and failure to maintain medication storage areas properly.
Failure to serve food at safe temperatures and maintain kitchen and food storage areas in a sanitary condition.
Failure to provide nourishing snacks at bedtime and document snack distribution and acceptance.
Failure to maintain a coordinated plan of care with hospice providers and ensure resident needs are met.
Failure to maintain an effective Quality Assessment and Assurance (QAA) program including lack of meetings and corrective action plans.
Failure to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failure to implement an antibiotic stewardship program to monitor and manage antibiotic use.
Report Facts
Medication errors: 5
Resident census: 59
Fall risk score: 16
Fall risk score: 10
Fall risk score: 14
Braden score: 12
Medication count missing signatures: 8
Temperature range: 32
Temperature range: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration errors and oxygen equipment observations. |
| CNA D | Certified Nurse Aide | Named in perineal care deficiencies and medication administration observations. |
| CNA E | Certified Nurse Aide | Named in pressure ulcer care and resident behavior incident. |
| Administrator | Interviewed regarding staffing, QAPI, and facility operations. | |
| Clinical Services Director | Interviewed regarding staffing, medication management, and resident care. | |
| Dietary Aide A | Interviewed regarding food preparation and serving practices. | |
| Activity Director | Interviewed regarding activities programming deficiencies. | |
| LPN B | Licensed Practical Nurse | Named in medication storage and treatment observations. |
| CMT A | Certified Medication Technician | Named in medication administration observations. |
Inspection Report
Routine
Census: 93
Deficiencies: 11
Date: Dec 13, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, care, medication administration, infection control, respiratory care, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meals, improper advance directive documentation, medication administration errors, inadequate respiratory care, failure to monitor smoking safety, unsafe water temperatures, food served at unsafe temperatures, and lapses in infection prevention practices.
Deficiencies (11)
Staff failed to assist residents with meals in a dignified manner, including standing while feeding and not sitting at eye level.
Facility failed to ensure appropriate verification of incapacity before allowing durable power of attorney to sign advance directives.
Staff failed to follow manufacturer guidelines and facility policy when administering insulin, eye drops, nasal sprays, and inhalers.
Staff failed to provide complete perineal care and did not change gloves or wash hands appropriately during incontinent care.
Facility failed to notify physician timely after straight catheterization without order and noted tea colored urine, resulting in resident hospitalization for UTI and sepsis.
Resident found with lighter in room contrary to facility smoking policy; water temperatures in resident-accessible faucets exceeded safe limits.
Staff failed to ensure oxygen therapy was administered according to physician orders, including failure to clean filters and monitor oxygen tank levels.
Medication administration errors occurred including failure to prime insulin pens before administration.
Staff failed to follow proper nasal spray administration technique including failure to have resident blow nose and occlude opposite nostril.
Food served to residents was sometimes cold and not at safe temperatures.
Staff failed to follow infection prevention practices including hand hygiene and glove changes during incontinent care and medication administration.
Report Facts
Facility census: 93
Medication error rate: 13.79
Insulin dose: 12
Insulin dose: 10
Insulin dose: 14
Oxygen liters: 2
Oxygen liters: 3
Oxygen liters: 2
Hot water temperature: 129.2
Hot water temperature: 126.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in undignified feeding and meal assistance observations |
| Director of Nursing | Director of Nursing | Provided interviews on multiple deficiencies including feeding, advance directives, medication administration, respiratory care, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding food service and resident complaints about food temperature and quality |
| LPN A | Licensed Practical Nurse | Observed administering insulin and oxygen therapy; interviewed about medication administration and oxygen use |
| CMT B | Certified Medication Technician | Observed administering eye drops and nasal spray |
| CNA I | Certified Nurse Aide | Observed providing perineal care without changing gloves or washing hands |
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