Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Capitol River Wellness & Rehabilitation during CMS and state inspections, most recent first.
Unfinished walls, missing base trim, exposed screws, and unpainted drywall were observed in multiple common areas, including the memory care unit, dining room, hallways, kitchenette, therapy area, and nurse's station area. A resident said the baseboards had been missing for over a year and that "we live here," while a CNA, an LPN, the Maintenance Director, the DON, and the administrator all described the condition as not homelike and acknowledged it had been left unresolved for months to over a year.
Facility staff failed to provide written bed hold policy information to residents or their representatives when residents were transferred to the hospital. Record review showed multiple residents had hospital transfers, including some who returned and some who did not, but their charts lacked documentation that the bed hold policy was given at discharge. The administrator acknowledged the deficiency, while the DON stated he/she had been told a bed hold signed on admission did not need to be provided again on transfers.
Failure to complete baseline care plans within the required timeframe affected six sampled residents. Facility policy required a person-centered baseline care plan within 48 hours of admission, but several residents had no completed plan or had one completed late. LPN, ADON, SSD, DON, and the administrator all acknowledged the importance of the baseline care plan and that nursing and social services were responsible for completing it, but some plans were still not done on time.
Staff failed to complete entrapment assessments for four residents using bed rails or enabler bars. Records showed the residents’ care plans allowed rails or enablers for bed mobility, while observations found fixed grab bars on both sides of the bed, including gaps of about six inches for one resident and three inches for another. Interviews showed confusion among nursing, therapy, maintenance, the DON, and the administrator about who was responsible for the measurements and assessments, and the maintenance staff said he/she had never known entrapment measurements were required.
A resident with an indwelling catheter, a resident with a suprapubic catheter, and another resident with an indwelling catheter were repeatedly observed with urinary drainage bags touching or resting on the floor in the wheelchair, at the nurse’s station, in the dining room, and during a transfer. Multiple staff members, including the DON, ADON, LPNs, CNAs, and an RA, saw the bags on the floor and did not correct them. Interviews confirmed staff knew catheter bags should not be on the floor because of contamination, hygiene, and infection concerns.
Two cognitively intact residents were not allowed to exercise their rights to receive mail unopened, as the business office manager opened their mail—sometimes without their presence—particularly when the mail was from sources like Medicaid or disability. Staff interviews confirmed this practice, which was not in accordance with the facility's resident bill of rights policy.
Staff failed to document required treatments and monitoring for four residents, including colostomy care, catheter care, blood glucose checks, and daily weights, despite physician orders and facility policy. Interviews with LPNs, the administrator, and the DON confirmed that all care and medication administration must be documented, and missing documentation is considered as care not provided.
The facility did not consistently provide the number of nurses, CNAs, and shower aides required by its own assessment, with multiple days showing staffing below the established minimums. Despite efforts to cover shifts through overtime and agency staff, the facility was unable to meet its staffing requirements, particularly during a period when several staff members were out sick.
The facility staff failed to adhere to food storage policies, leading to potential contamination and outdated use. Observations revealed torn gasket seals on a refrigerator, undated and improperly stored food items, and raw eggs stored over ready-to-eat foods. Interviews with the Dietary Manager and administrator highlighted lapses in daily checks and awareness of storage issues.
Facility staff failed to prevent the commingling of personal funds of 32 residents with the facility's operating funds. The Business Office Manager (BOM) was not adequately trained on a new billing system, leading to delays in processing refunds. The BOM admitted to reviewing the Accounts Receivable (A/R) Aging report monthly instead of weekly and acknowledged the responsibility for timely refunds, which were not being processed within the required 30 days. The administrator confirmed the BOM's responsibilities but could not explain the refund delays.
The facility failed to maintain a safe and clean environment, with observations of missing drywall, debris, and black substances in resident rooms and common areas. Staff interviews revealed inadequate reporting and communication of maintenance issues, with budget constraints and staffing shortages contributing to the lack of timely repairs and cleaning.
Facility staff failed to respect the dignity of two residents during meals by standing over them and referring to them as 'feeders,' contrary to facility policy. Observations showed CNAs and an LPN shouting at residents, compromising their dignity. Interviews revealed that staff were aware of the correct procedures but did not follow them, and the DON and administrator were unaware of these practices.
Unfinished Walls and Missing Base Trim
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by leaving multiple areas with missing base trim, exposed screws, unfinished drywall, and unpainted wall surfaces. Observations on the memory care unit, main dining area, 100 and 300 hallways, kitchenette, therapy department short hall, nurse's station area, and front halls showed walls below handrails left unpainted, gaps between floors and walls where base trim had been removed, a large hole in drywall between rooms, and exposed two-by-four lumber in an unfinished kitchenette wall. During interviews, a resident stated the baseboards had not been fixed for over a year and said, "we live here." A CNA, an LPN, the Maintenance Director, the DON, and the administrator all acknowledged the missing trim and unfinished walls, describing the condition as bad, not homelike, terrible, and present for months to over a year. The Maintenance Director said a hired company quit and the work had been left unfinished, while the administrator stated the baseboards had been gone for six months and that the condition was not homelike.
Failure to Provide Written Bed Hold Policy at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written information about the bed hold policy to residents and/or their representatives when residents were transferred to the hospital. Based on interview and record review, this occurred for eight residents sampled, including Residents #8, #12, #20, #28, #47, #67, #71, and #86. The facility policy titled "Bed Hold," dated June 2020, stated the facility notifies the resident or representative in writing of the bed hold policy any time the resident is transferred to a general acute care hospital. Review of the medical records showed multiple hospital transfers and returns, including residents who were discharged to the hospital and later returned to the facility, as well as residents who did not return. In each reviewed record, there was no documentation that staff provided the bed hold policy to the resident or responsible party at the time of discharge. During interviews, the administrator acknowledged the facility was deficient with bed holds and could not provide requested bed hold documentation. An LPN stated admissions staff had residents sign a bed hold on admission and when sent to the hospital, while the DON stated he/she had been told that once a bed hold is signed on admission another one does not need to be provided upon transfers.
Failure to Complete Baseline Care Plans Within Required Timeframe
Penalty
Summary
Facility staff failed to complete a baseline care plan within 48 hours of admission for six of 23 sampled residents, including Resident #8, #35, #62, #67, #71, and #86. The facility policy titled Care Planning, dated 06/2020, required a person-centered baseline care plan for each resident within 48 hours of admission and to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. Review of the records showed baseline care plans were not completed for Resident #8, Resident #67, and Resident #71, while Resident #35, Resident #62, and Resident #86 had baseline care plans completed after admission rather than within the required timeframe. During interviews, LPN H stated baseline care plans are completed by the charge nurse and SSD and are important so staff know the resident's goals and how to care for them. ADON A said baseline care plans should be completed by the admitting charge nurse and SSD, and that he/she is supposed to ensure they are completed, but could not give a reason why some were not done. The SSD said he/she tries to complete the social services section within the first 24 hours and that if he/she is gone, no one else completes that section. The DON stated baseline care plans should be completed within 48 hours and that the ADON should review the health records daily to ensure completion, while the administrator said baseline care plans should be completed within the first 24 hours and was not aware they were not getting done.
Missing Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
Facility staff failed to complete entrapment assessments for four residents who were using bed rails or enabler bars. The facility policy stated that before installing a bed rail, the resident must be assessed for entrapment risk and the bed dimensions must be appropriate for the resident’s size and weight, with maintenance/designee to assess bed dimensions at least quarterly. The policy did not address zone measurements for entrapment risk. Resident #5’s record showed the annual MDS documented bed rails were not used, but the care plan stated the resident was dependent on two aides for bed mobility. Observations on two separate days showed the resident in bed with grab bars in a fixed upright position on both sides of the bed. The medical record did not contain an entrapment assessment. Resident #9’s care plan documented assist rails for bed mobility, turning, and repositioning, and observations showed fixed grab bars on both sides of the bed with an approximate six-inch gap between the bar and mattress; the resident stated there had been issues with the space before. Resident #71’s care plan allowed enabler bars to aid bed mobility, and observations on four days showed bilateral grab bars in upright position, with no entrapment assessment in the record. Resident #83’s care plan allowed U-shaped enablers to improve independence and bed mobility, and observations showed grab bars on both sides of the bed with an approximate three-inch gap between the mattress and grab bars; the record also lacked an entrapment assessment. During interviews, the Maintenance Director said he/she had not been asked to complete any bed rail assessments and was unaware of entrapment assessments or the facility policy. An LPN said therapy assessed the resident and nurses completed bed rail assessments, but was unsure who was responsible for entrapment measurements. The ADON said maintenance should complete the entrapment measurements, while the maintenance assistant said he/she had never known that entrapment measurements needed to be done. The DON said maintenance was responsible for the assessments but did not know how often they were to be completed, and the administrator said staff were supposed to measure gaps for safety and that he/she was ultimately responsible for ensuring the assessments were done.
Urinary drainage bags left on the floor
Penalty
Summary
Facility staff failed to ensure sanitary conditions for urinary drainage bags for three residents with indwelling urinary catheters. The facility policy titled, Catheter-Care of, dated June 2020, stated catheter collection bags should always be kept below the level of the bladder, including during transport, and should not touch the floor at any time. Resident #5’s MDS dated 03/06/26 showed an indwelling urinary catheter, and the care plan dated 04/09/26 directed staff to keep the urinary collection bag off the floor. On 05/18/26, the resident was observed in a tilt-in-space wheelchair near the nurse’s station with the catheter bag resting on the floor, and multiple staff members, including the DON, ADON, RA, CNA, and LPN, walked past without correcting it. Resident #5 was also observed later that day in the dining room with the catheter bag on the floor under the wheelchair. On 05/19/26, during a bed-to-wheelchair mechanical lift transfer, CNA N laid the catheter bag on the floor while looking for a dignity bag, and CNA K remained in the room while the bag stayed on the floor until CNA N returned and placed it in the dignity bag. Resident #58’s quarterly MDS showed severe cognitive impairment and an indwelling catheter, and the care plan dated 05/08/26 required a suprapubic catheter. The resident’s catheter bag was observed on 05/18/26, 05/19/26, and 05/19/26 again touching the floor mat while hung from the bedframe. Resident #34’s quarterly MDS showed an indwelling urinary catheter, and the care plan dated 04/09/26 directed staff to keep the collection bag off the floor. The resident was observed on 05/20/26 at the nurse’s station and later in the dining room with the catheter bag touching or resting on the floor under the wheelchair. Staff including LPNs and CNAs were nearby during these observations and did not correct the placement. Interviews confirmed staff awareness that catheter bags should not be on the floor because of contamination, hygiene, and infection concerns, and the DON and administrator stated that catheter bags should never be on the floor.
Failure to Honor Residents' Rights to Unopened Mail
Penalty
Summary
Facility staff failed to honor residents' rights to receive mail unopened, as outlined in the facility's resident bill of rights policy. Two cognitively intact residents reported that the business office manager (BOM) opened their mail without their presence. One resident stated that the BOM opened mail in the office and then delivered it to the resident's room, admitting in an audio recording that mail from sources such as Medicaid and disability was routinely opened due to its potential impact on billing. The BOM also acknowledged to staff and during interviews that mail was opened, and in one instance, the envelope was discarded before the resident could review it. Another resident confirmed that the BOM would sometimes open important mail, such as correspondence about disability, before delivering it to the resident. Staff interviews corroborated that the BOM opened residents' mail and that this practice was not in accordance with facility policy. The administrator confirmed that staff are expected to follow the residents' bill of rights and should not open residents' mail.
Failure to Document Required Care and Monitoring for Multiple Residents
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the provision of required treatments and monitoring for four residents. Specifically, staff did not document colostomy care for a cognitively intact resident with an ostomy bag on several specified dates, despite physician orders and facility policy requiring such documentation. Similarly, for a resident with moderate cognitive impairment and an indwelling catheter, staff did not document catheter care, output recording, or catheter irrigation on two dates, as ordered by the physician. Additionally, staff failed to document blood glucose monitoring for a resident with diabetes mellitus on multiple dates, contrary to physician orders for three daily checks. Another resident, admitted with coronary artery disease and requiring daily weights for fluid retention management, had missing documentation of daily weights on three dates. Interviews with staff, the administrator, and the DON confirmed that all treatments and medication administrations are expected to be documented, and that missing documentation is treated as if the care was not provided.
Failure to Maintain Adequate Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment. The assessment specified the required number of direct care staff, including nurses and CNAs, for each shift based on the average daily census and resident needs. A review of the staffing schedule for the month showed multiple instances where the facility did not meet its own staffing requirements, such as having fewer nurses or CNAs than required, and often lacking day shower aides entirely on several days. These staffing shortfalls occurred despite the facility's census remaining consistent with the numbers used in the assessment. Interviews with the staffing coordinator and the administrator confirmed that the schedule was based on the facility assessment, but they acknowledged that staff shortages occurred, particularly due to numerous staff being out sick during the month. The administrator reported efforts to cover shifts by asking staff to stay over, come in, or by using agency staff, but the records show that the facility was still unable to consistently meet the staffing levels outlined in their assessment.
Food Storage Deficiencies Observed in Facility
Penalty
Summary
The facility staff failed to store food in a manner that prevents potential contamination and outdated use, as observed during a survey. The facility's Food Storage policy, dated 2016, outlines specific guidelines for storing food, including keeping food on shelves in a clean, dry area, labeling food items held for longer than 24 hours, discarding food past its expiration date, and ensuring proper refrigeration. However, observations revealed several violations of this policy. The gasket seals on the reach-in refrigerator were torn, and the refrigerator contained opened and undated cartons of honey thickened dairy drink and orange juice, as well as a pitcher of tomato juice and cranberry juice with discard dates that had passed. Additionally, a one-gallon pitcher of tea was dated well beyond the seven-day storage limit. An opened and undated bag of orange gelatin mix was found on a cart, and an opened bottle of Worcestershire sauce, which should have been refrigerated, was stored on a shelf. The walk-in freezer contained undated cases of vegetables and bread stick dough exposed to air, and a case of potato barrels was stored on the floor. Further observations showed raw eggs stored over ready-to-eat food items in the reach-in refrigerator, contrary to the facility's policy. Interviews with the Dietary Manager (DM) and the administrator revealed that both were responsible for ensuring proper food storage, with the DM expected to check food storage daily. The DM acknowledged that opened food items should be sealed, labeled, and dated, and that food requiring refrigeration should be stored accordingly. Despite these responsibilities, the DM was unaware of the torn gasket seals on the refrigerator doors. The administrator reiterated the importance of following food storage requirements and confirmed that all dietary staff were trained on these protocols.
Failure to Prevent Commingling of Resident Funds
Penalty
Summary
The facility staff failed to prevent the commingling of personal funds of 32 residents with the facility's operating funds. This issue was identified through interviews and record reviews, revealing that the Business Office Manager (BOM) had not been adequately trained on a new computer billing system, which went live recently. The BOM admitted to falling behind on processing refunds due to this lack of training and acknowledged that it was his/her responsibility to review the Accounts Receivable (A/R) Aging report weekly, although it was only being reviewed monthly. The BOM also confirmed that refunds should be processed within 30 days of a resident's discharge, but this was not being adhered to, resulting in significant amounts of residents' personal funds being held in the facility's operating account without written authorization. The administrator confirmed that the BOM was responsible for managing the A/R Aging report and resident billing, and expressed an expectation for the BOM to handle accounts consistently and ensure timely refunds. However, the administrator could not provide reasons for the delays in processing refunds. The facility's policy on collections guidelines was reviewed, which outlined the procedures for requesting refunds due to credit balances, overpayments, and other scenarios, but these procedures were not being followed, leading to the deficiency.
Environmental Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by numerous observations of environmental deficiencies. These included missing and torn drywall, visible footprints and debris on floors, black sticky substances, chipped paint, missing tiles, and black porous substances on ceilings and walls. The facility's housekeeping and maintenance procedures were not adequately followed, leading to these conditions being unaddressed. Interviews with staff revealed a lack of communication and reporting of maintenance issues. Staff members, including CNAs, LPNs, and housekeepers, acknowledged the presence of environmental concerns but often did not document or report them in the maintenance log. The maintenance director and housekeeping director were aware of some issues but cited budget constraints and staffing shortages as reasons for the lack of timely repairs and cleaning. The facility's policies and procedures for housekeeping and maintenance were not effectively implemented, resulting in a failure to address the environmental concerns. The maintenance director admitted to being aware of general issues but not the specific extent of the problems. The administrator and other staff members expressed a lack of awareness of certain deficiencies, indicating a breakdown in communication and oversight within the facility.
Failure to Respect Resident Dignity During Meals
Penalty
Summary
Facility staff failed to respect the dignity of two residents during meal times, as observed by surveyors. The facility's policy on dining experience and resident rights emphasizes promoting dignity and discourages staff from standing over residents while assisting them with meals. However, observations showed that Certified Nurse Aide (CNA) M stood over Residents #22 and #24 while assisting them with food, and referred to them as 'feeders,' indicating a lack of respect for their dignity. Additionally, CNA R and Licensed Practical Nurse (LPN) N were observed shouting at the residents, further compromising their dignity. Interviews with staff, including CNA R, LPN N, the Director of Nursing (DON), and the facility administrator, revealed a consensus that staff should not stand over residents or refer to them as 'feeders.' Despite this understanding, the practice continued, as evidenced by multiple observations of staff standing over residents during meals. The DON and administrator expressed unawareness of these practices, indicating a disconnect between policy and practice within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jefferson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Villa Marie | 0.5 mi | ★★★★★ | 9 | 0 |
| Stonebridge Adams Street | 0.8 mi | ★★★★★ | 4 | 0 |
| Jefferson City Manor Care Center | 1.1 mi | ★★★★★ | 8 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 1.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.