Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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The facility staff failed to adhere to food storage policies, leading to potential contamination and outdated use.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.
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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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 0 | 0 |
| Stonebridge Adams Street | 0.8 mi | ★★★★★ | 6 | 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 | ★★★★★ | 0 | 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 July 2026) and official state health department websites.