Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
67% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where one resident received another resident's medications.
Complaint Details
Complaint #2682543 regarding a medication error where Resident #1 received Resident #2's medications.
Findings
The facility failed to ensure Resident #1 remained free from accidents when Resident #1 received Resident #2's medications. The medication error occurred because staff were overwhelmed and did not properly verify the resident's identity before medication administration.
Deficiencies (1)
Facility staff failed to ensure one resident remained free from accidents when the resident received another resident's medications.
Report Facts
Facility census: 66
Medication dosages: 1500
Medication dosages: 75
Medication dosages: 200
Medication dosages: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Documented and involved in the medication error where Resident #1 received Resident #2's medications |
| Administrator | Interviewed regarding staff directions on medication administration | |
| DON | Director of Nursing interviewed regarding staff education on medication administration |
Inspection Report
Routine
Census: 65
Deficiencies: 5
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, medication management, infection control, facility maintenance, and antibiotic stewardship in the nursing facility.
Findings
The facility was found deficient in maintaining professional standards in medication transcription and administration, proper medication storage and destruction, kitchen ceiling maintenance, infection prevention practices including glucometer sanitation and PPE use, and implementation of an antibiotic stewardship program.
Deficiencies (5)
Failed to transcribe a treatment order for one resident and inaccurately transcribed a medication order for a Fentanyl patch for another resident.
Failed to destroy medications weekly and failed to store medications in locked compartments for 27 residents.
Failed to maintain the kitchen ceiling in good repair to prevent contamination of food items.
Failed to appropriately sanitize a multi-use glucometer between uses and failed to perform proper hand hygiene and glove changes during blood glucose checks; failed to use PPE for residents on enhanced barrier precautions.
Failed to implement an Antibiotic Stewardship Program with protocols and monitoring system.
Report Facts
Facility census: 65
Residents affected: 27
Medication counts: 23
Medication counts: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Nurse who obtained Fentanyl telephone order and entered it incorrectly into electronic MAR system | |
| Director of Nursing | DON | Responsible for reviewing and verifying orders, runs daily reports, and commented on deficiencies in medication transcription and infection control |
| Administrator | Provided statements on staff responsibilities and facility policies regarding medication orders, storage, and infection control | |
| Licensed Practical Nurse B | LPN | Observed failing to use approved disinfectant on glucometer and failing to use PPE during wound and catheter care |
| Licensed Practical Nurse A | LPN | Observed failing to perform hand hygiene and glove changes during blood glucose checks |
| Dietary Manager | DM | Aware of kitchen ceiling cracks and water leaks |
| Maintenance Director | Aware of kitchen ceiling cracks and water leaks, awaiting repairs |
Inspection Report
Routine
Census: 64
Deficiencies: 6
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, medication administration, medication storage, dietary services, and resident safety including call light accessibility.
Findings
The facility was found deficient in multiple areas including failure to update and revise resident care plans, improper medication preparation and storage practices, use of expired blood sugar test strips, lack of qualified dietary management staff, failure to wear facial hair restraints in food service, improper dish drying procedures, and failure to ensure call lights were within reach of residents.
Deficiencies (6)
Failure to review and revise care plans for residents with cellulitis and medication noncompliance.
Medication administration errors including pre-popping medications prior to timed pass and use of expired blood sugar test strips.
Failure to date opened multi-dose medication bottles and insulin vials; medications left unattended on medication cart.
Failure to employ a qualified full-time Director of Food and Nutrition Services.
Failure of dietary staff to wear facial hair restraints and failure to allow sanitized dishes to air dry before storage.
Failure to ensure call lights were within reach for three residents.
Report Facts
Facility census: 64
Medication cups prepared prior to medication pass: 40
Residents affected by medication administration deficiencies: 4
Residents affected by care plan deficiencies: 2
Residents affected by call light deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in medication administration and medication storage findings |
| LPN E | Licensed Practical Nurse | Named in medication administration and blood sugar testing findings |
| LPN H | Licensed Practical Nurse | Named in care plan and medication administration findings |
| Director of Nursing | Director of Nursing (DON) | Named in care plan, medication administration, and medication storage findings |
| Administrator | Facility Administrator | Named in care plan, medication administration, medication storage, and call light findings |
| DM | Dietary Manager | Named in dietary services and food safety findings |
| CNA F | Certified Nurse Aide | Named in call light findings |
| CNA G | Certified Nurse Aide | Named in call light findings |
Inspection Report
Routine
Census: 58
Capacity: 98
Deficiencies: 6
Date: Feb 24, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, medication management, infection control, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding and bathroom access, inadequate posting of abuse hotline information, poor environmental maintenance, unsafe medication storage and narcotic count discrepancies, unsanitary kitchen conditions and food storage practices, improper hand hygiene and infection control practices, and improper storage and maintenance of oxygen tubing and catheter drainage bags.
Deficiencies (6)
Failure to maintain resident dignity during feeding and bathroom access.
Failure to post telephone numbers for Adult Abuse and Neglect Hotline and Long-Term Care Ombudsman in accessible locations.
Failure to maintain a safe, clean, comfortable and homelike environment; including poor repair of walls, floors, and resident wheelchair condition.
Failure to ensure medications were stored properly and controlled medication counts were accurate.
Failure to maintain kitchen environment equipment in a clean and sanitary manner, protect light bulbs, properly store food, perform hand hygiene, sanitize sinks, and ensure ice machine drains through an air gap.
Failure to maintain an infection prevention and control program including improper hand hygiene, glove use, wound care, oxygen tubing storage, and catheter bag management.
Report Facts
Facility census: 58
Facility capacity: 98
Controlled medication count discrepancy: 9.5
Number of loose pills observed: 52
Number of residents affected by deficiencies: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in findings related to feeding dignity, bathroom access, glove use, and catheter bag handling |
| LPN C | Licensed Practical Nurse | Named in findings related to feeding dignity, medication counts, wound care, glove use, and oxygen tubing |
| Maintenance Director | Named in findings related to bathroom door locking and kitchen lighting maintenance | |
| Administrator | Named in findings related to posting requirements, environmental issues, medication storage, and infection control | |
| Director of Nursing | DON | Named in findings related to feeding dignity, posting requirements, environmental issues, medication storage, and infection control |
| Maintenance Supervisor | Named in findings related to maintenance log and prioritization of repairs | |
| Licensed Practical Nurse L | Licensed Practical Nurse | Named in findings related to medication cart cleanliness and narcotic counts |
| Dietary Manager | DM | Named in findings related to kitchen sanitation, food storage, hand hygiene, and ice machine maintenance |
| Certified Nurse Aide I | CNA | Named in infection control observation |
| Certified Nurse Aide J | CNA | Named in infection control observation |
| Nurse Aide K | NA | Named in infection control observation |
| Minimum Data Set Coordinator | MDS Coordinator | Named in infection control training and policy discussion |
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