Inspection Reports for The Jefferson City Nursing and Rehabilitation Center
MO, 65109
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
81 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Apr 28, 2025
Visit Reason
The inspection was conducted due to a complaint alleging that facility staff opened residents' mail without the residents being present, potentially violating residents' rights.
Complaint Details
The complaint was substantiated based on interviews with residents, staff, and the BOM, and review of residents' Minimum Data Sets (MDS) showing cognitive intactness. The BOM admitted to opening mail from Medicaid and disability before delivering it to residents.
Findings
The facility failed to ensure that two cognitively intact residents were allowed to exercise their rights regarding mail privacy, as the business office manager (BOM) opened their mail without their presence. Interviews and record reviews confirmed the BOM opened mail from Medicaid and disability sources before delivering it to residents.
Deficiencies (1)
Facility staff failed to ensure residents' rights were honored when staff opened residents' mail without the residents present.
Report Facts
Residents affected: 2
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Admitted to opening residents' mail before delivering it | |
| Administrator | Stated staff should never open residents' mail and expects staff to follow residents' bill of rights |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Mar 4, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, nursing staff adequacy, and documentation practices at the nursing facility.
Findings
The facility failed to maintain professional standards of care by not documenting colostomy care, catheter care, blood glucose monitoring, and obtaining weights for sampled residents. Additionally, the facility did not provide adequate nursing staff as determined by their facility assessment.
Deficiencies (5)
Failure to document colostomy care for one resident.
Failure to document catheter care and irrigation for one resident.
Failure to document blood glucose monitoring for one resident.
Failure to document obtaining daily weights for one resident.
Failure to provide adequate nursing staff as per facility assessment.
Report Facts
Facility census: 81
Average daily census: 88
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding documentation practices and reporting missed treatments |
| Administrator | Administrator | Interviewed regarding documentation responsibilities and staffing |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding documentation practices and staff responsibilities |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staff scheduling and staffing challenges |
Inspection Report
Census: 85
Deficiencies: 4
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident dignity, financial affairs management, environmental conditions, and food safety at Capitol River Wellness & Rehabilitation.
Findings
The facility was found deficient in respecting resident dignity during meal assistance, managing residents' personal funds separately from facility funds, maintaining a safe and clean environment with multiple maintenance and housekeeping issues, and properly storing food to prevent contamination and outdated use.
Deficiencies (4)
Facility staff failed to respect the dignity of two residents during meal time by standing over them and using inappropriate language.
Facility staff failed to prevent the commingling of 32 residents' personal funds with the facility operating funds.
Facility staff failed to provide a safe, clean, comfortable and homelike environment, with multiple issues including damaged walls, floors, ceilings, and air conditioning units.
Facility staff failed to store food properly, including storing raw foods over ready-to-eat foods, undated and opened food items, and food stored on the floor.
Report Facts
Residents affected: 2
Residents affected: 32
Facility census: 85
Total personal funds commingled: 128001.55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in dignity deficiency for standing over residents and referring to residents as feeders |
| CNA R | Certified Nurse Aide | Named in dignity deficiency for standing over residents and shouting at residents |
| LPN N | Licensed Practical Nurse | Named in dignity deficiency for shouting at residents and staff about feeding |
| CNA O | Certified Nurse Aide | Identified residents as feeders during interview |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity and maintenance issues |
| Administrator | Administrator | Interviewed regarding dignity, maintenance, and food storage deficiencies |
| Business Office Manager | Business Office Manager | Interviewed regarding commingling of residents' funds and refund delays |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental maintenance issues and reporting |
| CNA F | Certified Nurse Aide | Interviewed regarding maintenance reporting and environmental conditions |
| LPN I | Licensed Practical Nurse | Interviewed regarding maintenance reporting and environmental conditions |
| Housekeeper J | Housekeeper | Interviewed regarding cleaning practices and environmental conditions |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning schedules, staffing, and environmental conditions |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage practices and deficiencies |
Inspection Report
Routine
Census: 87
Deficiencies: 10
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, facility environment, medication administration, care planning, infection control, food and nutrition services, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, incomplete and inaccurate resident assessments, inadequate care planning, failure to meet professional standards in nursing care and medication administration, improper food handling and storage practices, insufficient dietary staff qualifications, and lapses in infection prevention and control practices.
Deficiencies (10)
Failure to maintain walls, floors, doors, door frames, trim, handrails, and windows in good repair, resulting in an unsafe and uncomfortable environment for residents.
Failure to document a complete and accurate Minimum Data Set (MDS) assessment for one resident, specifically related to falls.
Failure to develop and implement comprehensive person-centered care plans for nine residents, lacking measurable goals and specific interventions.
Failure to meet professional standards of care including failure to document neurological checks and fall follow-up for six residents and failure to follow physician orders for two residents.
Failure to follow up on Urinalysis and Culture with Sensitivity (UA C&S) lab results and delay in initiating treatment for two residents with urinary tract infections.
Failure to remove and destroy discontinued and outdated medications from medication carts and storage areas.
Failure to employ a qualified dietitian or clinically qualified nutrition professional full-time; dietary manager lacked required certification or education.
Failure to reheat pureed food items to required temperatures and failure to maintain hot food items at safe temperatures upon service.
Failure to perform hand hygiene consistently, improper handling and storage of sanitized dishes, failure to properly sanitize manually washed kitchenware, improper food storage practices, and failure to maintain clean food delivery equipment.
Failure to provide wound care in a manner to reduce the risk of infection, including lapses in hand hygiene and glove use during wound care.
Report Facts
Facility census: 87
Deficiency count: 10
Fall risk score: 75
Fall risk score: 65
Fall risk score: 55
Fall risk score: 105
Medication orders: 7
Medication orders: 7
Food temperature: 99.3
Food temperature: 107.4
Food temperature: 114
Food temperature: 108
Food temperature: 141
Food temperature: 108
Food temperature: 110
Food temperature: 108
Food temperature: 100
Food temperature: 115.8
Food temperature: 114
Food temperature: 115
Food temperature: 94.2
Food temperature: 87.7
Food temperature: 91.6
Food temperature: 110
Food temperature: 100
Food temperature: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in multiple findings related to fall assessments, medication administration, and wound care |
| DA D | Dietary Aide | Named in findings related to hand hygiene and dishwashing practices |
| DM | Dietary Manager | Named in findings related to food preparation, temperature monitoring, and food storage |
| MCU manager | Memory Care Unit Manager | Named in findings related to fall follow-up, medication orders, and staff supervision |
| Wound Nurse | Named in findings related to wound care and infection prevention | |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility policies and oversight |
| LPN FF | Licensed Practical Nurse | Named in fall follow-up documentation |
| LPN GG | Licensed Practical Nurse | Named in fall documentation and neurological checks |
| LPN II | Licensed Practical Nurse | Named in fall follow-up documentation |
| LPN JJ | Licensed Practical Nurse | Named in fall documentation |
| LPN KK | Licensed Practical Nurse | Named in fall documentation |
| LPN LL | Licensed Practical Nurse | Named in fall documentation |
| LPN MM | Licensed Practical Nurse | Named in fall documentation |
| LPN NN | Registered Nurse | Named in fall documentation |
| LPN OO | Licensed Practical Nurse | Named in interviews about maintenance requests and care plans |
| CNA Y | Certified Nurse Aide | Named in interviews and observations related to resident care and falls |
| CNA Z | Certified Nurse Aide | Named in interviews related to resident care and resistance to care |
| LPN W | Licensed Practical Nurse | Named in interview regarding PTSD care planning |
| Social Services Designee | Named in interview regarding PTSD care planning | |
| Assistant Director of Nursing | ADON | Named in multiple interviews regarding care planning, fall follow-up, medication errors, and staff responsibilities |
| Occupational Therapist EE | Occupational Therapist | Named in interview regarding resident brace order |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Nov 14, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's responsible party after the resident had a fall with injury and was transported to the hospital.
Complaint Details
The complaint investigation found that the facility staff did not notify the family of Resident #1 after a fall and hospital transfer, and did not document the notification as required. Interviews with Licensed Practical Nurses, the Director of Nursing, and the administrator confirmed the policy and expectations but revealed lapses in documentation and notification.
Findings
The facility staff failed to notify the responsible party of Resident #1 after a fall resulting in injury and hospital transfer. Interviews with nursing staff and administration confirmed the expectation to notify family and document such notifications, but documentation was missing.
Deficiencies (1)
Failure to notify the resident's responsible party when the resident had a fall with injury and was transported to the hospital.
Report Facts
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding notification responsibilities and documentation | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding notification responsibilities and documentation | |
| Director of Nursing (DON) | Interviewed regarding responsibility for ensuring notification and documentation | |
| Administrator | Interviewed regarding notification expectations and documentation responsibilities |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: Sep 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide 24-hour protective oversight for a resident, resulting in injury.
Complaint Details
The complaint investigation found that staff failed to monitor Resident #1 adequately, resulting in the resident being found injured after a prolonged period without checks. The immediate jeopardy was identified on 9/22/23 and removed on 9/24/23 after corrective actions.
Findings
The facility failed to conduct visual checks on Resident #1 from 6:45 P.M. on 09/22/23 to 8:26 A.M. on 09/23/23, leading to the resident being found on the floor with injuries including a fractured rib. Staffing shortages and lack of proper monitoring policies contributed to the incident.
Deficiencies (2)
Failure to provide 24-hour protective oversight and conduct visual checks on Resident #1, resulting in injury.
Inadequate nursing staff on the Memory Care Unit (MCU) during the night shift of 9/22/23, with only one Nurse Aide responsible for 23 residents.
Report Facts
Facility census: 93
Residents on MCU: 23
Staff to resident ratio: 1
Staffing requirement ratio: 10
Staffing requirement ratio: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide B | Nurse Aide | Failed to conduct visual checks during scheduled shift on 9/22/23; reported feeling overwhelmed being the only staff on MCU. |
| Licensed Practical Nurse C | Licensed Practical Nurse | Responsible nurse for MCU during night shift; did not lay eyes on Resident #1 and failed to check on all residents. |
| Certified Nurse Aide A | Certified Nurse Aide | Gave verbal report to NA B on 9/22/23; assisted Resident #1 before shift ended. |
| Registered Nurse H | Registered Nurse | Documented assessment of Resident #1 after found injured; did not receive report from staff. |
| Administrator | Administrator | Interviewed regarding staffing and monitoring policies; unaware of staffing shortage on 9/22/23 night shift. |
| Director of Nurses | Director of Nurses | Stated staff are expected to round every two hours and give report room to room. |
| Staffing Coordinator | Staffing Coordinator | Aware only one staff was scheduled on MCU; did not know why no replacement came in. |
| Emergency Room Nurse Practitioner | Nurse Practitioner | Assessed Resident #1 at hospital with multiple injuries including rib fracture. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide dignified care and proper medication administration, as well as failure to maintain a clean and safe environment for residents.
Complaint Details
The complaint investigation revealed failures in dignified care, environmental cleanliness, medication administration documentation, and timely physician notification of lab results.
Findings
The facility failed to provide dignified care to a resident by leaving them soiled for extended periods, failed to clean a resident's mattress properly, and failed to document medication administration and timely notify physicians of lab results for multiple residents. The facility census was 86.
Deficiencies (3)
Facility staff failed to care for one resident in a dignified manner by leaving the resident soiled for an extended period before and after care was provided.
Facility staff failed to provide one resident with a clean and comfortable environment when staff did not clean the resident's mattress as recommended by the manufacturer.
Facility staff failed to meet professional standards by not documenting medication administration and failing to notify physicians timely of lab results for multiple residents.
Report Facts
Facility census: 86
Medication administration documentation omissions: 50
Lab result reporting delay: 5
Lab result reporting delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Mentioned in relation to failure to clean resident's mattress and medication administration documentation |
| LPN D | Licensed Practical Nurse | Mentioned in relation to failure to clean resident's mattress and medication administration documentation |
| CNA H | Certified Nurse Aide | Mentioned in relation to incontinence care and failure to clean mattress |
| CNA I | Certified Nurse Aide | Mentioned in relation to incontinence care and failure to clean mattress |
| LPN E | Licensed Practical Nurse | Responsible for auditing medication administration records and mentioned in lab result delays |
| LPN F | Licensed Practical Nurse | Responsible for auditing medication administration records and mentioned in lab result delays |
| CMT G | Certified Medication Technician | Mentioned in relation to incontinence care and medication administration documentation |
| Director of Nursing | Director of Nursing | Mentioned regarding staff responsibilities for incontinence care and medication administration audits |
| Administrator | Administrator | Mentioned regarding facility policies on mattress cleaning and medication administration |
Inspection Report
Routine
Census: 86
Deficiencies: 1
Date: Mar 3, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically regarding COVID-19 practices and compliance with CDC and facility policies.
Findings
The facility failed to maintain an effective infection prevention and control program by not separating COVID-19 positive residents from those who tested negative or were only exposed, resulting in increased risk of COVID-19 transmission among residents. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (1)
Failed to maintain an infection prevention and control program to prevent spread of COVID-19 by not separating positive COVID-19 residents from negative or exposed residents.
Report Facts
Facility census: 86
Residents affected: 3
Dates of positive COVID-19 tests: Resident #1 positive on 2/22/23, Resident #3 positive on 2/22/23, Resident #5 positive on 2/23/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding residents remaining in rooms with COVID positive roommates | |
| Infection Preventionist | Interviewed about not removing residents who tested negative after roommate tested positive | |
| Administrator | Interviewed about room availability and decisions not to move residents |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 3, 2023
Visit Reason
The inspection was conducted as an annual survey of Capitol River Wellness & Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were reported as unknown.
Inspection Report
Census: 84
Deficiencies: 7
Date: Aug 16, 2022
Visit Reason
The inspection was conducted based on a Life Safety Code tour and review of medication management, food service, infection control, and vaccination compliance at the facility.
Findings
The facility was found deficient in maintaining a clean and safe environment, proper medication management for psychotropic drugs, food temperature and safety, infection prevention and control including water management, and staff vaccination compliance. Multiple resident rooms and common areas were in disrepair, psychotropic medications lacked appropriate diagnoses and dose reductions, food was served at unsafe temperatures, food storage and kitchen hygiene were inadequate, no water management program was in place, and staff COVID-19 vaccination compliance was incomplete.
Deficiencies (7)
Facility staff failed to maintain resident rooms and common areas clean and in good repair, including missing floor coverings, mold-like substances on ceilings, broken drywall, missing bathroom doors, missing window screens, and damaged exit doors.
Facility staff failed to ensure medication regimens were free from unnecessary psychotropic medications and failed to include diagnoses in medication orders for multiple residents.
Facility staff failed to maintain hot food at or above 120°F and cold food at or below 41°F at the time of meal service and failed to implement a system for monitoring food temperatures.
Facility staff failed to store food properly to prevent cross-contamination and outdated use, maintain kitchen environment and equipment in sanitary condition, and failed to use gloves and perform hand hygiene as required.
Facility staff failed to develop and implement policies and procedures for inspection, testing, and maintenance of water systems to inhibit growth of waterborne pathogens and reduce risk of Legionnaire's Disease.
Facility staff failed to maintain and follow policies and procedures for pneumococcal vaccinations for residents in accordance with national standards.
Facility staff failed to ensure all staff were fully vaccinated for COVID-19, failed to ensure medical exemptions included required information, and failed to ensure providers under contract were vaccinated or exempt.
Report Facts
Facility census: 84
Staff vaccination rate: 96
Number of direct hire staff: 113
Number of contracted staff: 8
Resident COVID-19 infections: 4
Resident hospitalizations: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed about facility maintenance and water management program | |
| Director of Nursing | DON | Interviewed about medication management, vaccination compliance, and infection prevention |
| Administrator | Interviewed about facility policies and responsibilities for maintenance and vaccination | |
| Certified Medication Technician P | CMT | Interviewed about housekeeping and resident room cleanliness |
| Housekeeping staff C | Interviewed about cleaning routines | |
| Housekeeping supervisor | Interviewed about cleaning schedules and logs | |
| Resident #54's representative | Interviewed about room cleanliness complaints | |
| Dietary Aid A | Interviewed about food tray delivery and temperature monitoring | |
| Dietary cook B | Interviewed about food temperature checks and complaints | |
| Licensed Practical Nurse F | LPN | Interviewed about expectations for food temperature |
| Wound Care Nurse | Interviewed about expectations for meal temperature | |
| Registered Dietician | RD | Observed and interviewed about glove use and hand hygiene |
| Licensed Practical Nurse E | LPN | Interviewed about infection preventionist role in vaccination tracking |
| Registered Nurse D | RN | Interviewed about vaccination clinic and follow-up |
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