Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
37 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe and appropriate pain management for a resident who required such services after knee replacement surgery.
Complaint Details
The complaint investigation found that the facility did not document administration of pain medication to address the resident's pain. The resident experienced moderate to severe pain, and staff delays in obtaining physician orders and medication delivery contributed to inadequate pain management. The resident and family expressed dissatisfaction with pain control and medication availability.
Findings
The facility failed to ensure timely administration and documentation of appropriate pain medication for Resident #93, admitted after knee replacement surgery. Staff delays in obtaining physician orders and medication delivery resulted in the resident experiencing moderate to severe pain without adequate pain control. Non-pharmacological interventions and Tylenol were provided, but narcotic pain medications were delayed due to lack of signed physician orders and pharmacy delivery issues.
Deficiencies (1)
Failure to provide safe, appropriate pain management and timely administration of pain medication for a resident after knee replacement surgery.
Report Facts
Facility census: 37
Pain level: 5
Pain level: 6
Pain level: 7
Medication dosage: 2
Medication dosage: 500
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Conducted pain assessment, admitted resident, responsible for narcotic medication drawer |
| RN F | Registered Nurse | Documented resident upset about lack of pain medication, called pharmacy for STAT delivery |
| LPN N | Licensed Practical Nurse | Administered hydromorphone and documented pain levels |
| CMT A | Certified Medication Technician | Documented resident pain levels |
| CNA K | Certified Nurse Aide | Assisted resident, reported resident's pain complaints |
| LPN M | Licensed Practical Nurse | Charge nurse on 05/25/25, assessed resident pain, did not administer pain medication |
| LPN L | Licensed Practical Nurse | Discussed medication order delays and pain assessment |
| LPN G | Unit Manager | Explained admission medication procedures and pharmacy delivery times |
| ADON | Assistant Director of Nursing | Administered Tylenol to resident, communicated about pain management |
| Director of Nursing | Director of Nursing | Discussed documentation and medication administration procedures |
| Administrator | Administrator | Discussed expectations for timely pain medication administration and pharmacy delivery |
| Corporate Staff | Described process for receiving and activating physician orders for new admissions |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care, including inadequate wound assessment, lack of physician orders for treatment, and failure to update care plans for wounds.
Complaint Details
The investigation was complaint-related, focusing on pressure ulcer care deficiencies. The complaint was substantiated with findings of inadequate wound assessment, treatment, and documentation.
Findings
The facility failed to document full wound assessments upon admission, obtain physician orders for wound treatment, and update care plans for skin breakdown interventions for one resident out of seven sampled. Staff did not consistently document wound treatments or progress notes, and the resident's wounds worsened during the stay. Interviews with staff confirmed lapses in wound care documentation and treatment initiation.
Deficiencies (1)
Failed to provide care per professional standards related to pressure ulcers, including failure to document full wound assessments upon admission, failure to obtain physician's orders for treatment and interventions, and failure to update care plans regarding skin breakdown intervention changes.
Report Facts
Residents Affected: 1
Facility Census: 37
Wound measurements: 1.8
Wound measurements: 1.5
Wound measurements: 2.6
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Aug 5, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to timely report an allegation of abuse involving a resident (Resident #3) and concerns about pressure ulcer care for two residents (Residents #1 and #2).
Complaint Details
The complaint involved an allegation by Resident #3 that two nurses humiliated and inappropriately touched him/her during a skin assessment. The facility delayed reporting the allegation to the state survey agency by seven days. Interviews with staff revealed confusion and failure to report within the required two-hour timeframe.
Findings
The facility failed to timely report an allegation of abuse to the state survey agency within the required two-hour timeframe. Additionally, the facility failed to provide appropriate pressure ulcer care, including incomplete wound assessments, failure to obtain and follow physician orders, and failure to update care plans for two residents with pressure ulcers.
Deficiencies (2)
Failed to timely report an allegation of abuse involving one resident to the state survey agency within the required two-hour timeframe.
Failed to provide appropriate pressure ulcer care including incomplete wound assessments, failure to obtain physician orders, failure to follow ordered treatments, and failure to update care plans for two residents.
Report Facts
Facility census: 36
Resident #3 admission date: Jul 23, 2024
Resident #3 MDS date: Jul 29, 2024
Resident #1 admission date: Jul 19, 2024
Resident #1 wound measurements: 4
Resident #1 wound measurements: 3.5
Resident #2 admission date: Jul 5, 2024
Resident #2 wound measurements: 1.5
Resident #2 wound measurements: 4.5
Resident #2 wound measurements: 7.2
Resident #2 wound measurements: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Admitted Resident #3 and involved in skin assessment during alleged abuse incident |
| CNA C | Certified Nurse Aide | Assisted LPN A during skin assessment of Resident #3 during alleged abuse incident |
| SSD | Social Services Director | Met with Resident #3 regarding abuse complaint and reported to DHSS |
| ADON | Assistant Director of Nursing | Interviewed regarding abuse allegation and investigation |
| DON | Director of Nursing | Interviewed regarding abuse allegation and wound care practices |
| LPN B | Licensed Practical Nurse | Provided care and observations related to Resident #1's wounds |
| LPN E | Licensed Practical Nurse (Wound Nurse) | Responsible for wound measurements and wound care documentation |
| RN D | Registered Nurse | Interviewed regarding skin assessments and wound care procedures |
| Administrator | Responsible for reporting abuse and overseeing facility compliance | |
| Medical Director | Provided expert opinion on skin breakdown prevention |
Inspection Report
Routine
Census: 37
Deficiencies: 8
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication self-administration, resident assessments, code status documentation, medication error rates, food safety, infection control, and staff tuberculosis testing.
Findings
The facility was found deficient in multiple areas including failure to ensure proper approval and care planning for resident self-administration of medications, incomplete and untimely resident assessments, inconsistent documentation of resident code status, medication errors related to insulin administration and pen priming, improper food storage and dish drying practices, incomplete documentation of fentanyl patch administration, and failure to complete required tuberculosis testing for residents and staff.
Deficiencies (8)
Failed to ensure interdisciplinary team approval, physician orders, and care planning for resident self-administration of medication for two residents with medication at bedside.
Failed to complete a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident.
Failed to ensure resident code status was accurate and consistent throughout the medical record for three residents.
Failed to ensure medication error rate was less than 5% due to incorrect insulin type and dosage administration and failure to prime insulin pens for two residents.
Failed to ensure residents were free from significant medication errors related to insulin administration and pen priming for two residents.
Failed to store food in sealed containers, stack dishes only when dry, and maintain dishwasher rinse temperatures at recommended levels, risking contamination.
Failed to document administration and placement of fentanyl patch in the Medication Administration Record (MAR) for one resident.
Failed to maintain an effective infection prevention program by not ensuring two residents and three staff members received required tuberculosis testing per standards and guidance.
Report Facts
Facility census: 37
Medication error rate: 7.4
Fentanyl patch dosage: 50
Dishwasher rinse temperature: 167
Tuberculosis skin test induration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Failed to complete second step of tuberculosis testing |
| CMA M | Certified Medication Assistant | Failed to complete tuberculosis testing |
| CNA N | Certified Nurse Aide | Tuberculosis test read after maximum allowed time, requiring retesting |
| CMT A | Certified Medication Technician | Described medication administration and documentation practices |
| RN B | Registered Nurse | Described medication administration and documentation practices |
| RN C | Registered Nurse | Described medication administration and insulin pen use practices |
| LPN I | Licensed Practical Nurse | Described insulin pen administration practices |
| Dietary Aide G | Described food storage and dish drying practices | |
| Dietary Manager | Described food storage and dish drying practices | |
| Administrator | Provided statements on medication administration, food safety, and infection control | |
| DON | Director of Nursing | Oversaw medication administration, infection control, and tuberculosis testing |
| ADON | Assistant Director of Nursing | Oversaw tuberculosis testing and infection control |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to an allegation of misappropriation of property by a staff member who took medications belonging to a resident. The investigation focused on the missing medication and failure to administer medication as ordered.
Complaint Details
The complaint was substantiated. The allegation of misappropriation was made to DHSS on 2023-08-23. Video footage showed the nurse taking pills from a resident's medication bottle and disposing of the bottle. The nurse returned the medication after being confronted and was arrested. The resident missed several doses of medication due to this incident.
Findings
The facility failed to keep residents free from misappropriation of property when a registered nurse took a resident's medication and failed to administer medication as ordered for four days. The medication was recovered but could not be administered. The nurse was arrested for stealing medication. The facility also failed to ensure medication was administered as ordered, resulting in missed doses for the resident.
Deficiencies (2)
Failed to protect residents from wrongful use of belongings or money when a staff member took resident medication.
Failed to provide care in accordance with professional standards by not administering medication as ordered for four days.
Report Facts
Pills returned: 164
Resident census: 35
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Staff member who took resident medication and was arrested for stealing medication. |
| CMT B | Certified Medication Technician | Reported missing medication to the Director of Nursing. |
| DON | Director of Nursing | Notified of missing medication and involved in investigation. |
| HR Manager | Reviewed video footage, confronted RN A, and called police. | |
| RN E | Registered Nurse | Documented medication administration error and noted missing medication. |
| LPN D | Licensed Practical Nurse | Notified about missing medication from the cart. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to obtain orders and properly change PICC line dressings for one resident, and failure to administer insulin as ordered for another resident, resulting in hospitalization.
Complaint Details
The complaint investigation revealed failure to obtain and document orders for PICC line dressing changes and failure to administer insulin as ordered, resulting in resident harm including hospitalization.
Findings
The facility failed to obtain physician orders for PICC line dressing changes and failed to change the dressing per professional standards for Resident #2. Additionally, the facility failed to administer insulin as ordered for Resident #1 for two days, leading to hospitalization with hyperglycemia. The facility census was 33.
Deficiencies (2)
Failed to obtain orders regarding when to change a PICC line dressing and failed to change the dressing per professional standards for one resident.
Failed to ensure residents were free from significant medication errors when staff failed to administer insulin as ordered for two days for one resident, resulting in hospitalization.
Report Facts
Facility census: 33
Days without PICC line dressing change order: 16
Days without PICC line dressing change order: 17
Days insulin not administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding PICC line dressing change procedures and expectations |
| RN B | Registered Nurse | Interviewed regarding order entry responsibilities and medication administration |
| RN C | Registered Nurse | Interviewed regarding admission order entries and medication administration |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding admission order entry and missed insulin orders |
| RN E | Registered Nurse | Hospital nurse interviewed regarding resident admission to ICU with hyperglycemia |
| Director of Nursing | Interviewed regarding expectations for order entry and medication administration | |
| Administrator | Interviewed regarding expectations for order entry and medication administration |
Inspection Report
Routine
Census: 38
Deficiencies: 3
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to assess compliance with regulations related to food service quality, resident food preferences, and infection prevention and control practices at the facility.
Findings
The facility failed to ensure food was served at a palatable temperature, accommodate a resident's food preferences, and maintain proper infection control practices including proper use of face masks and cleaning of glucometers between residents.
Deficiencies (3)
Failed to ensure food served to residents was palatable, attractive, and at an appetizing temperature.
Failed to accommodate one resident's intolerances and food preferences.
Failed to provide and implement an infection prevention and control program, including improper cleaning of glucometers and improper wearing of face masks by staff.
Report Facts
Facility census: 38
Meal trays on hall cart: 17
Contact time for disinfectant: 3
Date of inspection: Jul 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) F | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Certified Nursing Assistant (CNA) G | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Certified Medication Technician (CMT) H | Mentioned in relation to resident complaints about cold food and food preference communication | |
| Dietary Manager | Provided information on food temperature policies and food preference documentation | |
| Director of Nursing (DON) | Provided information on food complaints and infection control practices | |
| Administrator | Provided information on food service procedures and mask policies | |
| Licensed Practical Nurse (LPN) A | Observed performing glucometer testing and cleaning | |
| Licensed Practical Nurse (LPN) B | Observed performing glucometer testing and cleaning | |
| Registered Nurse (RN) E | Observed wearing mask improperly | |
| Housekeeper D | Observed wearing mask improperly | |
| Physical Therapy Assistant (PTA) C | Observed wearing mask improperly | |
| Certified Nurse Aide (CNA) K | Provided information on mask policies | |
| RN L | Provided information on mask policies |
Inspection Report
Routine
Census: 25
Deficiencies: 2
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with care planning requirements and medication management, including review of residents' code status documentation and use of psychotropic medications.
Findings
The facility failed to ensure that one resident's comprehensive care plan was revised to reflect the resident's choice for code status, and failed to provide a rationale for continuing an as needed psychotropic medication beyond 14 days for another resident. The facility census was 25.
Deficiencies (2)
Failed to revise one resident's comprehensive care plan to include the resident's choice for code status.
Failed to provide a rationale to continue an as needed psychotropic medication past 14 days for one resident.
Report Facts
Facility census: 25
Residents in sample: 12
PRN alprazolam administration dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) A | Interviewed regarding code status placard system | |
| Social Service Director | Interviewed regarding admission procedures and code status documentation | |
| MDS Coordinator | Interviewed regarding documentation of code status on care plans | |
| Director of Nursing (DON) | Interviewed regarding expectations for code status documentation and medication review | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding administration of PRN anti-anxiety medications |
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