Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Gasconade Manor Nursing Home during CMS and state inspections, most recent first.
A facility failed to consistently use EBP, hand hygiene, and proper glove technique during catheter care, wound care, and mechanical lift transfers for several residents with catheters and wounds. Staff entered rooms with EBP signage without gowns, changed gloves without hand hygiene, used the same washcloth area repeatedly on catheter tubing, and performed wound care with soiled gloves and uncleaned scissors. Interviews showed staff were unsure of EBP requirements and the DON, ADON, and IP acknowledged inconsistent compliance.
Failure to Complete Quarterly EDL Checks: Facility staff did not follow the EDL Protocol by failing to complete quarterly EDL re-checks for six of 10 sampled employees, including a CNA, housekeeper, LPN, dietary aide, RN, and CMT. HR said he/she checked staff every four to six months, could not locate the quarterly EDL checks, and did not know the checks were required every three months. The administrator said HR was responsible for the quarterly checks and that he/she had assumed they were being completed per policy.
Failure to inspect bed canes and reassess entrapment zones for multiple residents. Staff did not complete regular bedrail inspections for one resident and did not remeasure or reassess entrapment zones for three residents who used bed canes. Records showed only earlier entrapment measurements, while repeated observations found the bed canes upright on both sides. Interviews showed the maintenance director, ADON, and administrator were unclear about who was responsible for ongoing measurements and all stated the measurements were not updated regularly.
Failure to provide bed hold notices and Ombudsman notification for hospital transfers. Staff did not give written bed hold information to residents or their representatives for three residents who were transferred to the hospital, and the records did not show Ombudsman notification. Interviews showed the SSD, RN, ADON, and administrator did not complete bed holds for hospital transfers and were unaware the Ombudsman should be notified.
Opened medications in a medication cart were found without open dates, including multiple OTC products, nasal spray, eye drops, and solutions. Staff interviews confirmed that bottles should be dated when opened and that open dates are checked to help ensure medications are not expired, but several containers in the cart were still undated.
The facility staff failed to maintain the mechanical dishwasher, resulting in ineffective sanitization of dishes due to low water temperatures. Staff did not consistently check temperatures, which were below the required 120°F, and continued using the dishwasher. Additionally, improper food storage practices were observed, including undated and unsealed items, increasing cross-contamination risks.
The facility failed to provide scheduled weekend activities for residents, as confirmed by interviews with two residents and staff. The activity calendar showed no activities on several Sundays, and staff indicated that activities were dependent on nursing staff availability. The Director of Nursing acknowledged the inconsistency, and the administrator confirmed that weekend activities were not listed on the schedule.
Facility staff failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A resident with diabetes did not receive properly administered insulin due to staff not priming the Humalog Kwik Pen as required. Observations and interviews confirmed the oversight, which affected the resident's insulin dosage.
The facility failed to post required nurse staffing information in an accessible location, placing it behind a locked door and omitting essential details like the facility name, census, and total hours worked. Staff interviews confirmed the deficiency, with the RN unaware of the requirements and the DON acknowledging changes to the form. Administrators stated the information should be posted on a dry erase board outside the nurse's station.
Failure to Use EBP, Hand Hygiene, and Proper Glove Technique During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not use Enhanced Barrier Precautions (EBP), did not perform appropriate hand hygiene, and did not use gloves correctly during catheter care, wound care, and mechanical lift transfers for five sampled residents. The facility policy stated that residents with indwelling devices or wounds required EBP, including gown and glove use during high-contact care activities such as transferring, hygiene, device care, and wound care. The hand hygiene and glove use policies required hand hygiene before donning gloves, after removing gloves, and when moving from dirty to clean tasks. Resident #5 had severe cognitive impairment, pressure ulcers, and physician orders for bilateral heel wound care, sacral wound care, and catheter care three times daily. Observations showed the resident’s door did not have EBP signage on multiple occasions, the catheter hung below the chair and later touched the floor, and CNA J and RN F performed catheter care and wound care without gowns. During catheter care, CNA J used the same portion of the washcloth to cleanse the groin area and catheter tubing. During wound care, RN F removed a soiled dressing, did not change gloves or wash hands before cleansing and redressing the wounds, used the same scissors without sanitizing them, and continued care with soiled gloves. RN F also left the room after removing gloves without hand hygiene. Resident #6 had a surgical wound and was incontinent of bowel and bladder. Although an EBP sign was posted, CNA Q, NA R, and CMT D transferred the resident with a mechanical lift without gowns, assisted with toileting, removed gloves and washed hands, then reentered and provided care again without gowns. Resident #8 had an indwelling urinary catheter and a current UTI; CNA C and CNA B used gowns and gloves inconsistently, left the room and returned without hand hygiene, changed gloves without hand hygiene, and used the same portion of a washcloth repeatedly on the catheter tubing. Resident #34 had wound care orders for the coccyx and left buttock; RN F and CMT G entered with gloves only, placed supplies on the bedside table without a barrier, removed a soiled dressing, continued wound care with the same soiled gloves, applied medi-honey with gloved fingers, and did not perform hand hygiene during or after the procedure. Resident #42 had an indwelling catheter and toileting dependence; RN F performed catheter care without a gown, wiped the groin and catheter tubing repeatedly with the same washcloth area, touched the resident’s blanket with soiled gloves, removed gloves, handled the trash bag and door, and left without hand hygiene. Staff interviews showed multiple employees did not understand EBP requirements, glove changes, or hand hygiene expectations, and the administrator, ADON, and infection preventionist acknowledged that staff were not consistently following the signage and infection control practices.
Failure to Complete Quarterly EDL Checks
Penalty
Summary
Facility staff failed to follow the facility’s Employee Disqualification List (EDL) Protocol by not completing quarterly EDL re-checks for six of 10 sampled staff members: a CNA, housekeeper, LPN, dietary aide, RN, and certified medication technician. The facility policy dated 06/17/24 required quarterly review of new EDL listings to ensure current employees were not disqualified, but the employee files reviewed showed no quarterly EDL checks completed since each staff member’s hire date. During interviews, Human Resources stated he/she tried to check current staff against the EDL every four to six months and did not have a list of employees run against the EDL. Human Resources later said he/she could not find any of the quarterly EDL checks and did not know staff had to be checked every three months. The administrator stated Human Resources was responsible for running quarterly EDL checks, that checks were to be completed before employment and then quarterly per facility policy, and that he/she did not know why the checks had not been completed. The administrator also stated he/she was responsible for making sure Human Resources ran the quarterly EDL checks and had assumed Human Resources was doing so per policy.
Failure to Inspect Bed Canes and Reassess Entrapment Zones
Penalty
Summary
Facility staff failed to conduct inspections of bedrails as part of the regular maintenance program for one resident and failed to remeasure and reassess all possible entrapment zones for three residents. The facility policy stated that adaptive equipment should be regularly inspected to ensure safety, and the facility’s records showed that bed entrapment measurements were completed for the affected residents only on earlier dates, with no additional measurements documented afterward. The maintenance director stated he/she was responsible for completing entrapment measurements for residents who use bed canes, but said he/she only performed the measurements on admission or if a bed was changed and did not complete them as part of a regular maintenance program. The administrator also stated the measurements were only completed upon admission. Resident #2’s record showed cognitive intactness, dependence on staff for bed mobility, and use of bed canes for turning and repositioning. Resident #8’s record showed cognitive intactness, dependence for transfers, substantial to maximum assistance for rolling in bed, and use of bed canes for turning and repositioning. Resident #9’s record showed severe cognitive impairment, maximum assistance for bed mobility, and use of bed canes for turning and repositioning. For each of these residents, observations on multiple dates showed the bed canes in the upright position on both sides, while the medical record contained only the earlier entrapment measurements and no updated reassessments. Resident #57’s record showed severe cognitive impairment, maximum assistance for bed mobility, and use of bed canes for turning and repositioning. The medical record showed entrapment measurements were not completed on the documented date and contained no additional measurements. Observations on multiple dates showed the resident’s bed with bed canes in the upright position on both sides. During interviews, staff members stated they did not know who was responsible for completing entrapment measurements or whether they were updated regularly, and the ADON stated maintenance was responsible for installing the bed canes but did not know who completed the entrapment measurements or if they were updated regularly.
Failure to Provide Bed Hold Notices and Ombudsman Notification
Penalty
Summary
Facility staff failed to provide written bed hold information to residents and/or their representatives when residents were transferred to the hospital. Based on interview and record review, this occurred for three residents out of 17 sampled. The facility’s Bed Hold Policy, dated 10/17/23, stated that when a resident leaves the facility for hospitalization, a charge will not be calculated with anticipated return. Resident #6 was discharged to the hospital on 04/04/25 and returned on 04/10/25, Resident #38 was discharged on 06/12/25 and returned on 06/16/25, and Resident #57 was discharged on 04/10/25 and returned the same day. Their records did not contain documentation that staff issued a bed hold to the resident or responsible party, and the records also did not show that the Ombudsman was notified of the transfers/discharges. During interviews, the SSD, RN, ADON, and administrator stated they did not complete bed holds for hospital transfers and did not know the Ombudsman should be notified of resident transfers.
Opened Medications Left Undated in Medication Cart
Penalty
Summary
Facility staff failed to ensure multi-dose medications were dated when opened in one of two medication storage carts. During observation of the 200-hall medication cart, multiple opened medication containers were found without open dates, including Sodium Chloride 1 gram, Fluticasone Propionate 500 mcg nasal spray, Equate eye itch relief drops, 0.25% Acetic Acid 1,000 ml bottle, ABC complete vitamin, Vitamin C 500 mg, Vitamin D 2000 mg, Vitamin B12 500 mcg, Stool Softener 50 mg/8.6 mg, Gas-X 125 mg, Antacid, and Clearlax. The facility policy titled Medication Protocol directed staff to label or record the date when stock medication is opened and to check for expired medications. During interview, the CMT stated that when staff open a bottle of medication they are supposed to put the open date on the bottle, including OTC medications, nasal sprays, eye drops, and solutions, and said the purpose is to make sure the medication is not expired. The RN stated medication bottles should contain an open date and that CMTs should check for open dates since they use the carts. The ADON stated medication bottles should be initiated by the staff member who opens them and that CMTs should put open dates on every bottle when opened, while the Administrator stated whoever opens the bottle is responsible for putting the open date on it and that the charge nurse and DON are responsible for ensuring open dates are put on medication bottles.
Dishwasher Maintenance and Food Storage Deficiencies
Penalty
Summary
The facility staff failed to maintain the mechanical dishwasher in good repair, resulting in ineffective washing and sanitizing of dishes, which could lead to cross-contamination. Observations on multiple occasions showed that the Certified Dietary Manager (CDM) and dietary staff did not check the water temperature during the wash and rinse cycles, which were consistently below the manufacturer's recommended minimum of 120 degrees Fahrenheit. The CDM and staff were unaware of the low temperatures, and the facility lacked a policy for the use and maintenance of the dishwasher, although staff were trained upon hire. On several occasions, the dishwasher's water temperature was recorded as being below the required 120 degrees Fahrenheit, with temperatures ranging from 110 to 117 degrees Fahrenheit. Despite this, staff continued to use the dishwasher, placing potentially unsanitized dishes on the clean side of the station. Interviews with staff revealed that they were aware of the temperature requirements but continued to use the dishwasher due to operational needs, such as preparing meals for residents. Additional observations in the kitchen revealed improper food storage practices, including undated and improperly sealed food items, which could further contribute to cross-contamination risks. The CDM acknowledged these issues, stating that food should always be dated and sealed properly. The administrator confirmed that staff were responsible for monitoring the dishwasher's condition and temperature, and if issues persisted, they should report them for repairs.
Lack of Scheduled Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the residents' interests on weekends for two residents out of a sample of two, with a facility census of 61. The facility's policy on resident activities, which is undated, states that activities should enhance residents' well-being and promote their physical, cognitive, and emotional health. The Activity Director is responsible for completing an Activity Assessment within 72 hours of a resident's admission to implement an effective daily activity program. However, a review of the facility's activity calendar for May 2024 showed that no activities were scheduled on several Sundays, and interviews with residents and staff confirmed the lack of scheduled activities on weekends. Interviews with residents revealed dissatisfaction with the absence of weekend activities, as they expressed willingness to participate if activities were offered. Staff interviews, including those with a Certified Medication Technician, a Registered Nurse, and the Director of Nursing, indicated that activities on weekends were not regularly scheduled and were dependent on nursing staff availability. The Director of Nursing acknowledged that activities were not consistently provided on weekends, and the administrator confirmed that weekend activities were not listed on the schedule, leaving residents unaware of available options.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during the observation period. Out of 25 medication administration opportunities observed, two errors were identified, affecting one resident diagnosed with diabetes who was receiving insulin injections. The errors involved the improper administration of insulin using a Humalog Kwik Pen, where the staff did not prime the pen before administering the insulin, as required by the facility's Insulin Administration Policy. The resident's Physician Order Sheet indicated the use of a Humalog Kwik Pen for insulin administration three times a day, and the Medication Administration Record documented specific instances of insulin administration. However, observations revealed that Certified Medication Technicians failed to prime the insulin pen on two separate occasions, which was confirmed during interviews with the staff involved and the Director of Nursing. The failure to prime the insulin pen could result in the resident not receiving the correct amount of insulin, as acknowledged by the staff and the Director of Nursing.
Inaccessible and Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to comply with state and federal guidelines by not posting the required nurse staffing information in an easily accessible location for residents and visitors. Observations on two consecutive days revealed that the nurse staffing information was placed behind a locked door at the nurse's desk, making it inaccessible. Additionally, the posted information was incomplete, lacking the facility name, resident census, and total hours worked by direct care nursing staff. Interviews with facility staff, including an RN, the Director of Nursing (DON), and the administrators, confirmed the deficiency. The RN was unaware of the required information for the posting, and the DON acknowledged that the form had been changed and moved behind the nurse's station. The administrators confirmed that the posting should include specific details such as the date, facility name, census, and staffing numbers, and should be placed on a dry erase board outside the nurse's station for accessibility.
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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 Owensville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Owensville | 2.7 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Sullivan | 19.5 mi | ★★★★★ | 1 | 0 |
| Cuba Manor Inc | 20.3 mi | ★★★★★ | 0 | 0 |
| Meramec Nursing | 20.3 mi | ★★★★★ | 1 | 0 |
| New Haven Care Center | 21.6 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.