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 Gower Convalescent Center, Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically assaulted by another cognitively impaired resident, who grabbed and shook their hair. Both had care plans requiring separation and supervision, but these were not effectively implemented, resulting in a failure to prevent the abuse. Staff were present but not directly supervising at the time, allowing the incident to occur before intervention.
The facility failed to follow professional standards for food safety and sanitation, with issues in food storage, labeling, and temperature monitoring. Staff did not consistently wash hands or change gloves between serving residents, and hairnets were not properly worn. The kitchen and dining areas were cluttered, and food items were improperly stored. Interviews revealed a lack of adherence to facility policies and expectations.
The facility failed to maintain resident dignity during meal service and personal hygiene care. Observations showed inconsistent meal service, with residents at the same table not being served simultaneously, causing frustration. Additionally, a cognitively impaired resident was not consistently shaved, despite preferences and facility policy. Staff interviews revealed inconsistencies in care and documentation, highlighting deficiencies in adhering to resident rights and care plans.
The facility failed to maintain privacy for two residents by not posting signage for 24-hour camera surveillance and not obtaining consents. One resident's care plan did not address video surveillance with audio, and there were no physician's orders. Observations showed video monitors in rooms without proper signage. Staff were unaware of the need for signage or orders, considering the devices as communication tools requested by families.
The facility failed to update and document care plans for several residents, leading to discrepancies between the residents' current needs and their care plans. A resident's care plan was outdated, not reflecting their non-ambulatory status, while another's did not include wheelchair use despite frequent observations of such use. Additionally, care plan meetings were not documented or held quarterly as required, affecting the quality of care provided.
The facility failed to ensure professional standards of care by not verifying electronic medical records before providing wound care and administering insulin. A resident received wound treatment without order verification, while two residents had their blood sugars checked and insulin administered without confirming orders. Staff relied on routine practice rather than checking current orders, leading to deficiencies in care.
Two residents with severe cognitive impairment and high risk for skin injury were not repositioned every two hours as required, leading to deficiencies in care. Observations showed extended periods in reclining wheelchairs without repositioning, despite staff expectations for repositioning every two hours. The facility lacked a policy on positioning, contributing to the deficiency.
The facility staff failed to ensure residents were free from accident hazards by pushing them in wheelchairs without foot pedals, affecting four residents. Observations showed residents' feet dragging on the floor, despite staff beliefs that residents could hold their feet up. The facility lacked a clear policy on wheelchair safety, leading to inconsistent practices and deficiencies in resident care.
The facility failed to provide proper respiratory care for two residents, leading to potential bacterial exposure and discomfort. Oxygen tubing was found on the floor, and humidifier water levels were inadequate. Staff interviews revealed lapses in maintenance and documentation of oxygen equipment cleaning and management.
The facility failed to maintain a medication error rate below five percent, resulting in an 8% error rate affecting two residents. A CMT improperly administered artificial tears by allowing the dropper tip to touch a resident's eyelids and eyelashes. Additionally, an LPN administered Fiasp insulin to a resident 31 minutes before they began eating, instead of within the required 15 minutes. Both incidents were acknowledged by the staff involved and the DON.
The facility failed to securely store medications, affecting two residents. Medications were accessible to unauthorized individuals, with keys left in the medication cart lock. Resident medications were found at bedside without proper orders, and expired medications were not destroyed. Staff confirmed these practices were against policy.
The facility did not provide state-approved training for paid feeding assistants, impacting 18 residents. Five feeding assistants lacked formal training, receiving only one-on-one instruction from the DON and staff. The DON was unaware of the state training requirement, leading to non-compliance.
A facility failed to implement proper infection control measures for a resident readmitted with influenza A, lacking transmission-based precautions and signage. Additionally, clean laundry was transported uncovered, contrary to CDC guidelines. The DON and Administrator acknowledged these lapses.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when another resident physically assaulted them by grabbing their hair and jerking their head. Both residents involved had severe cognitive impairments, with diagnoses including dementia, Alzheimer's disease, and anxiety disorders. The assaulted resident had a care plan specifying to keep them away from the aggressor, while the aggressor's care plan included instructions for seating at a distance from others, constant observation, and separation from the assaulted resident. On the evening of the incident, both residents were seated near the nurses' station. Staff members, including a CNA and an LPN, were present but not directly supervising the residents at the moment of the altercation. The CNA was cleaning a wheelchair and facing away, while the LPN was behind the desk. The incident occurred when the aggressor came up behind the other resident, grabbed their ponytail, and shook their head, causing the victim to scream. Staff intervened after hearing the scream and separated the residents. Documentation and interviews confirmed that the care plans for both residents included measures to prevent such interactions, specifically to keep them apart and to supervise the aggressor closely. However, these interventions were not effectively implemented at the time of the incident, resulting in a failure to prevent the physical abuse. The facility's policy required prompt reporting and intervention in cases of abuse, but the lack of direct supervision and failure to maintain separation contributed to the occurrence of the event.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple observations of improper food storage, preparation, and sanitation practices. Staff neglected to date the receipt of incoming products in the dry storeroom and failed to label and date used products in the freezer and refrigerator. Additionally, leftovers in the refrigerator were not labeled, dated, or disposed of in a timely manner. The facility also did not monitor refrigerator and freezer temperatures daily, and sanitation requirements for cleanliness, handwashing, and hairnets were not consistently followed in the kitchen and dining room. Observations in the kitchen revealed several deficiencies, including opened bags of cereal without dates or labels, plastic cups stored face up, and a cluttered and unorganized kitchen area with trip hazards. The temperature log for the refrigerator and freezer was not up to date, and there was no thermometer in the freezer to record temperatures. In the dry storeroom, several food items were opened and undated, and a dented can was used to hold a door open, posing a potential safety risk. The freezer contained opened and resealed food items without labels or dates, and some food items were stored directly on the floor. In the dining room, staff members were observed not changing gloves or washing hands between serving residents, and pre-staged drinks were left uncovered. Staff members also failed to follow proper hygiene practices, such as wearing hairnets and beard covers correctly. Interviews with the Dietary Manager, Dietician, Maintenance Supervisor, and Administrator revealed a lack of adherence to facility policies and expectations regarding food safety and sanitation practices. The facility's new temperature monitoring application was not fully operational, and there was no plan in place to address potential failures of the system.
Deficiencies in Meal Service and Personal Hygiene Care
Penalty
Summary
The facility failed to maintain the dignity of its residents during meal service and personal hygiene care. Observations revealed that during meal times, residents seated at the same table were not served simultaneously, leading to some residents watching others eat while they waited for their meals. This inconsistency in meal service was noted by several residents, who expressed frustration and confusion over the random manner in which meals were served. The facility's policy requires that all residents at a table be served at the start of dining service, but this was not adhered to, except in cases where diabetic residents needed to be prioritized. Additionally, the facility did not ensure that a resident, who was severely cognitively impaired and dependent on assistance for personal hygiene, was free of facial hair. Despite the resident's preference for being shaved during showers, observations showed that the resident had noticeable facial hair on multiple occasions. Interviews with staff indicated that shaving was supposed to occur during showers provided by hospice staff, but there was a lack of documentation and consistency in this care aspect. The Director of Nursing expected female residents to be free from facial hair, but acknowledged the resident's resistance to care at times. The facility's failure to adhere to its policies on resident dignity and personal care resulted in deficiencies that affected the quality of life for its residents. The lack of consistent meal service and personal hygiene care, particularly for a resident with cognitive impairments, highlights the need for improved adherence to care plans and resident rights as outlined in the facility's policies.
Failure to Maintain Privacy with Video Surveillance
Penalty
Summary
The facility failed to maintain the privacy of two residents by not posting signage indicating 24-hour camera surveillance and not obtaining consents from the responsible parties. Resident #73's care plan did not address the use of video surveillance with audio, and there was no physician's order for such surveillance. Observations showed video monitors in the resident's room and at the nurse's station, but no signs were posted to indicate video monitoring. The Director of Nursing (DON) and staff were unaware of the need for signage or physician's orders, considering the devices as communication tools requested by the family. Resident #43 also had a video monitor in the room without proper signage or consent from the responsible party. The resident's care plan mentioned a V-tech baby monitor for monitoring due to a history of falls, but there was no signed consent for 24-hour surveillance. Interviews with staff revealed a lack of awareness regarding the need for care planning, physician's orders, and signage for video surveillance. The DON stated that the family installed the monitors, and she did not consider them as requiring notification or orders.
Deficiencies in Care Plan Development and Documentation
Penalty
Summary
The facility failed to ensure that care plans were developed and updated in accordance with the specific conditions and needs of the residents. This deficiency affected five residents, with issues ranging from outdated care plans to the lack of documentation of care plan meetings. For instance, Resident #23's care plan had not been updated since September 2024, despite changes in their condition, and there was no record of care plan meetings being held since March 2023. The resident expressed uncertainty about attending care plan meetings, and the facility staff did not document whether the resident or their family was invited or attended these meetings. Resident #47's care plan did not accurately reflect their current non-ambulatory status, as it still included instructions for using a sit-to-stand lift, which had not been used for over a year. Observations confirmed that the resident was dependent on a mechanical lift for transfers, yet the care plan had not been updated to reflect this change. Interviews with facility staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, corroborated the resident's decline and the need for updated care planning. Additionally, Resident #71's care plan failed to address the use of a wheelchair, despite multiple observations of the resident being transported in one. The facility also did not document care plan meetings for Residents #6 and #12, with both residents unsure if they had been invited or attended such meetings. The facility's MDS Coordinator and Social Services Designee acknowledged the lack of documentation and the failure to hold quarterly care plan meetings, as required. These deficiencies highlight significant lapses in the facility's care planning processes, impacting the quality of care provided to the residents.
Failure to Verify Medical Orders for Wound Care and Insulin Administration
Penalty
Summary
The facility failed to ensure professional standards of quality in care by not utilizing the electronic medical record to verify orders when providing wound care and administering medications. Specifically, staff did not verify orders for wound care for a resident, and did not check the electronic medical record before obtaining blood sugars and administering insulin for two other residents. This lack of verification was observed during the administration of insulin and wound care, where staff relied on memory or routine practice rather than confirming current orders. One resident, who was diabetic and required blood sugar monitoring and insulin administration, had their blood sugar checked and insulin administered without the nurse verifying the orders on the electronic medical record. The nurse admitted to not using a computer to verify orders due to the resident's long-term stay at the facility. Another resident, also diabetic, had their blood sugar checked and insulin administered without order verification, with the nurse acknowledging the lack of a portable device to check orders during the process. Additionally, a resident with a wound on the right posterior hip received treatment without the nurse verifying the specific order for the amount of collagen powder to be used. The nurse, who was responsible for wound care, did not check the electronic medical record before proceeding with the treatment, relying instead on their familiarity with the resident's care needs. Furthermore, another resident with a wound on the right calf did not have a physician's order for wound care, and the primary physician was unaware of the lack of orders, indicating a communication gap in the facility's care processes.
Failure to Reposition and Provide Incontinent Care
Penalty
Summary
The facility failed to provide adequate care and treatment in accordance with professional standards for two residents, leading to deficiencies in repositioning and incontinent care. Resident #47, who had severe cognitive impairment and was dependent on staff for mobility and repositioning, was observed to remain in a reclining wheelchair for extended periods without being repositioned. Despite being at high risk for skin injury and pressure sores, the resident was not laid down or repositioned as required, and staff interviews confirmed that the resident stayed in the chair most of the day. Similarly, Resident #72, who also had severe cognitive impairment and was dependent on staff for all activities of daily living, was not repositioned every two hours as required. The resident had a documented stage 4 pressure ulcer and was at high risk for further skin injury. Observations showed that the resident remained in a reclining wheelchair for several hours without repositioning, and staff interviews indicated that the resident was typically kept in the chair until after lunch. Interviews with various staff members, including CNAs, LPNs, and the DON, revealed a general expectation that residents should be repositioned every two hours. However, the observations and interviews indicated that this standard was not consistently met, particularly for residents in reclining wheelchairs. The facility did not provide a policy on positioning, contributing to the deficiency in care for these residents.
Failure to Ensure Wheelchair Safety for Residents
Penalty
Summary
The facility staff failed to ensure residents remained free from accident hazards by pushing residents in their wheelchairs without foot pedals. This deficiency affected four residents, who were observed being pushed with their feet dragging on the floor. The facility did not provide a policy on accidents, which contributed to the lack of consistent safety measures for residents in wheelchairs. Resident #1, with severe cognitive impairment and a history of falls, was observed being pushed without foot pedals, causing their feet to drag on the floor. Despite having an anti-roll back device on their wheelchair, the resident's care plan did not address the absence of foot pedals during transport. Interviews with staff revealed a belief that the resident could hold their feet up, but observations showed otherwise. Similarly, Resident #58, who was dependent on a wheelchair and required substantial assistance, was pushed without foot pedals on multiple occasions. Staff interviews indicated that residents were asked if they could hold their feet up, but this practice was inconsistent and not documented in care plans. Resident #68, with functional limitations and a history of falls, was also pushed without foot pedals, despite their care plan specifying the need for foot rests. Lastly, Resident #71, who was independent with walking but used a wheelchair, was pushed without foot pedals, with no care plan addressing wheelchair use. The facility's lack of a clear policy and inconsistent staff practices contributed to these deficiencies.
Improper Respiratory Care and Oxygen Tubing Management
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, resulting in potential exposure to bacteria and minor discomfort. For one resident, the oxygen tubing was observed lying on the floor, and the water container in the oxygen humidifier was only one-third full, with no dates indicating when the tubing or water bottle was last changed or cleaned. The resident reported slight discomfort due to a dry nose. Additionally, there was no record of oxygen administration or cleaning of tubing in the resident's Medication Administration History or Treatment Administration Record. For another resident, the oxygen tubing was also found lying on the ground with the nasal cannula exposed and in contact with the floor. There was no care planning for oxygen therapy at night, and no dates were taped to the tubing to indicate the last change or cleaning. Interviews with staff revealed that maintenance is responsible for cleaning the filters on oxygen humidifiers, and tubing and water cannisters are supposed to be cleaned weekly. However, the tubing should not be left on the floor, and staff are expected to use a Ziplock bag to prevent contact with the floor. The administrator and DON confirmed that oxygen tubing and nasal cannula should not be on the ground and should be dated when changed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8%. This affected two residents. The first incident involved a Certified Medication Technician (CMT) administering artificial tears to a resident. During the administration, the tip of the eye dropper touched the resident's eyelids and eyelashes, which is against the facility's policy and standard practice for administering eye drops. Both the CMT and the Director of Nursing (DON) acknowledged that the tip of the eye dropper should not touch the resident's eyelids or eyelashes. The second incident involved a Licensed Practical Nurse (LPN) administering Fiasp insulin to a resident. The insulin was given 31 minutes before the resident began eating, contrary to the requirement that a meal should be served within 15 minutes of administering fast-acting insulin. The LPN and the DON both confirmed that the resident should have been served their meal immediately after receiving the insulin. These errors contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications securely, affecting two residents. Medications for these residents were found to be accessible to unauthorized staff and residents. Specifically, medications were not stored in a locked area, and the key was left in the lock of the medication treatment cart. Additionally, expired and loose medications were found in the medication room and cart, which were not destroyed as required. Resident #44, who has multiple diagnoses including anemia, heart failure, and diabetes, was found to have a bottle of Refresh Tears at their bedside without a physician's order to self-administer medications. The resident's care plan did not include any orders for self-administration of medication, and the resident reported that their daughter had provided the eye drops after a medical procedure. Similarly, Resident #5, who requires staff assistance for medication administration, was found with a plastic med cup containing three pills at their bedside. The resident reported that staff had left the pills without explaining what they were, and the resident refused to take them until they knew their purpose. The medication treatment cart was repeatedly observed with the key left in the lock, unattended, and accessible to residents. Staff interviews confirmed that the key should not be left in the lock and that the cart should be secured when not in use. Additionally, expired medications and a loose pill were found in the medication cart and room, which should have been destroyed according to facility policy. The DON confirmed that expired and loose medications should not be present and should be destroyed.
Lack of State-Approved Training for Feeding Assistants
Penalty
Summary
The facility failed to provide state-approved training for paid feeding assistants, affecting 18 residents out of a census of 78. A review of the facility's list of paid feeding assistants revealed that five individuals had not completed the required formal training. During interviews, a nurse aide admitted to not attending a state-approved course, instead receiving one-on-one training from the Director of Nursing (DON) and experienced staff. The DON confirmed that each feeding assistant underwent one-on-one training on specific topics but was unaware of the requirement for state-approved training courses, indicating a lack of compliance with regulatory standards.
Infection Control and Laundry Transport Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures for a resident who was readmitted with a positive test for influenza A. Upon the resident's return, there were no transmission-based precautions in place, and no signage was posted to indicate the need for such precautions. The resident, who had been hospitalized for influenza, was not isolated immediately, and the necessary personal protective equipment was not utilized by staff. Observations showed that the resident's room lacked appropriate signage, and the infection preventionist was unaware of the resident's return and the need for precautions. Additionally, the facility did not ensure that clean laundry was protected from contamination during transport. Observations revealed that clean laundry, including resident gowns and underpads, was transported on uncovered metal carts through the facility's hallways. Interviews with laundry aides confirmed that the carts used for transporting clean laundry were not covered, contrary to CDC guidelines for environmental infection control. The facility's Director of Nursing and Administrator acknowledged the lapses in infection control and the failure to protect clean laundry from contamination. Despite the facility's policy and CDC guidelines, the necessary precautions and protective measures were not implemented, leading to deficiencies in infection prevention and control practices.
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gower
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakridge Of Plattsburg | 8 mi | ★★★★★ | 16 | 0 |
| Nick's Health Care Center | 8.5 mi | ★★★★★ | 13 | 1 |
| Belleview Care Center | 14.2 mi | ★★★★★ | 2 | 0 |
| Living Community Of St Joseph | 15.6 mi | ★★★★★ | 0 | 0 |
| St Joseph Manor Health & Rehabilitation | 16.8 mi | ★★★★★ | 2 | 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.