Above 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 Heisinger Bluffs Healthcare Western Campus during CMS and state inspections, most recent first.
A registered nurse serving as DON was found to lack required documentation and eligibility to work, as their nursing license became inactive due to immigration and visa issues. The facility did not have policies guiding verification of employment eligibility, and the RN continued to be paid and perform some tasks while on paid time off until the issue was identified and employment was terminated.
A facility failed to follow its grievance protocol when a resident's missing cellular phone was reported by a family member. The facility did not document the investigation or actions taken, and there was no designated grievance officer, leading to potential oversight of grievances. The administrator admitted to the lack of documentation and a grievance officer, contributing to the deficiency.
Facility staff failed to complete Resident Inventory Listings for three residents and required residents to waive liability for lost belongings. The Resident Handbook stated the facility is not responsible for lost items, and interviews revealed a lack of accountability and audit processes for inventory completion.
Facility staff failed to maintain a professional standard of care by leaving medications unattended at the dining room table, failing to ensure that residents took their medications. An RN left medications in front of residents and walked away, failing to verify that the medications were taken. Interviews confirmed that staff should ensure residents take their medications and not leave them unattended.
The facility failed to secure hazardous chemicals and objects in three rooms and did not properly secure the medicine cart, posing accident hazards. A resident was unsafely transferred using a mechanical lift, left suspended without support. Staff acknowledged these lapses, which violated facility policies on safety and medication storage.
Facility staff failed to protect residents' private medical information by leaving computer screens open and visible on medication carts and a nurse desk. An LPN and an RN left screens unattended, displaying residents' medical information. Both acknowledged the need to close or lock screens to protect privacy. The DON and Administrator confirmed monthly privacy education for staff.
A resident with severe cognitive impairment and pressure ulcers experienced an unwitnessed fall, but staff failed to perform the required 72-hour cognitive assessments. Additionally, the facility did not document necessary details for the resident's pressure ulcers as per policy. Interviews revealed a lack of awareness among staff and administration regarding these omissions.
Facility staff failed to notify a resident's physician and representative of an unwitnessed fall and a room change. The resident, who had cognitive impairments and a history of hip fracture, experienced a fall that was not communicated to their representative until a visit revealed the injury. Additionally, the resident was moved to a private room due to COVID-19 without proper notification.
Failure to Verify RN Employment Eligibility and License Status
Penalty
Summary
Facility staff failed to ensure that a registered nurse (RN) employed as the Director of Nursing (DON) had the required documentation to work in Missouri. Review of the RN's employee file showed no documentation confirming eligibility to work at the facility, and the facility's policies did not provide guidance on verifying eligibility to work in the state. The RN, who was from another country and on a school visa, was unable to renew their nursing license due to issues with immigration paperwork. Despite this, the RN continued to be paid for regular hours and participated in facility activities such as a science fair and reviewing referrals, while using paid time off. Interviews with facility staff revealed that the RN's license became inactive after the loss of their visa, and the human resources manager did not verify the RN's employment eligibility status. The administrator and HR manager acknowledged that the RN was not eligible to work once the visa and license issues arose, but the RN remained on payroll and performed some tasks until the situation was brought to their attention. The RN was ultimately terminated after it was confirmed that they were no longer eligible for employment.
Failure to Implement Grievance Protocol for Missing Cellular Phone
Penalty
Summary
The facility failed to implement its grievance protocol for a resident who reported a missing cellular phone. The facility's policies required that all grievances be investigated, documented, and resolved promptly, with a written decision provided upon request. However, in this case, the facility did not document the investigation or the actions taken in response to the grievance. The resident's family member reported the missing phone to the facility, but there was no evidence that a grievance form was completed or that the grievance was logged and investigated as per the facility's policy. Interviews revealed that the facility did not have a designated grievance officer, and there was no paper trail for grievances, which could lead to grievances being overlooked. The administrator acknowledged the lack of documentation and the absence of a designated grievance person, which contributed to the failure to properly address the resident's grievance. The resident confirmed the phone was missing and had informed their family member, but not the staff directly. The facility's failure to follow its grievance policy resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Complete Resident Inventory and Liability Waiver Issues
Penalty
Summary
The facility staff failed to ensure that the admission policy did not require residents or their responsible parties to waive facility liability for loss or damage to personal belongings. Additionally, the staff did not complete a Resident Inventory Listing for three residents upon their admission. The facility's Resident Personal Property policy allows residents to have personal belongings, and staff are directed to inventory and document these items upon admission. However, the Resident Handbook policy states that the facility is not responsible for lost or missing items, which includes personal effects such as jewelry, money, and other valuables. The medical records of the three residents did not contain documentation of completed Resident Inventory Listing forms, despite the residents or their representatives signing the Resident Handbook form acknowledging receipt of the handbook. Interviews with facility staff, including a Registered Nurse, the administrator, and the Director of Nursing (DON), revealed a lack of clarity and accountability regarding the completion of inventory sheets. The nursing staff were identified as responsible for completing the inventory sheets upon admission, but there was no audit process in place to ensure this was done. The administrator and DON were unaware of who was responsible for completing the inventory sheets for the three residents and acknowledged that the facility did not reimburse for missing or lost items. The DON admitted to overlooking the verification of completed inventory sheets in the residents' medical records.
Medication Administration Deficiency
Penalty
Summary
Facility staff failed to maintain a professional standard of care by leaving medications unattended at the dining room table, failing to ensure that residents took their medications. This deficiency was observed in three residents out of a total of 17 observed, with a facility census of 58. The facility's Medication Administration policy requires that medications be administered by licensed personnel and that staff remain with residents until medications are swallowed. However, observations showed that an RN left medications in front of residents and walked away, failing to verify that the medications were taken. Resident #7, assessed as cognitively intact, was observed multiple times with medication left in front of them without supervision. Similarly, Resident #19 and Resident #26, both assessed as cognitively impaired, were left with medications unattended. Interviews with RN D and the Director of Nursing confirmed that staff should ensure residents take their medications and not leave them unattended. The administrator also stated that staff are expected to remain with residents during medication administration to prevent others from taking the medication.
Failure to Secure Hazardous Items and Ensure Safe Resident Transfers
Penalty
Summary
The facility staff failed to secure potentially hazardous chemicals and objects in three rooms on the 100 hall and did not properly secure the medicine cart on the 300 hall, leading to potential accident hazards. Observations revealed that the 100 hall spa, laundry, and supply room doors were left open, unsecured, and unattended, with various hazardous items such as wound cleanser, adhesive remover, zinc oxide cream, ethyl alcohol-based wipes, odor eliminator, perineal cleanser, nail clippers, and disposable razors accessible. Interviews with staff, including a Certified Medication Technician, a Registered Nurse, the Director of Nursing, and the administrator, confirmed that these items should have been locked up to prevent resident access and potential harm. Additionally, the facility staff failed to safely transfer a resident using a mechanical lift. The resident, who was cognitively impaired and dependent on staff for all transfers, was left suspended in the air without hands-on support while staff repositioned a wheelchair. Interviews with the involved CNAs and other staff, including the DON and the administrator, acknowledged that two staff members should be present during mechanical lift transfers to ensure the resident's safety, and that leaving a resident suspended could lead to injury. The facility's policies on medication storage and administration were not adhered to, as evidenced by a nurse leaving the medication cart unlocked and unattended on two occasions. This was observed on the 300 hall, where multiple residents and staff passed by the unsecured cart. Interviews with the involved RN, the DON, and the administrator confirmed that the medication cart should have been locked when not in use to prevent unauthorized access and ensure safety.
Failure to Protect Resident Privacy
Penalty
Summary
The facility staff failed to protect residents' private medical information by leaving computer screens open and visible to the public on two medication carts and one nurse desk. On one occasion, an LPN left a medication cart unattended with the computer screen open while administering medications, making residents' medical information visible. The LPN acknowledged the mistake, stating that staff are required to close or lock the screen to protect residents' private information. Another incident involved a computer screen at the nurse's desk being left open and visible to the public, displaying private resident medical information. Additionally, an RN stepped away from a medication cart with the computer screen open, showing a resident's medication information, while four residents and a staff member were in proximity. The RN admitted that the screen should have been closed or minimized to protect resident privacy, even if stepping away for a short time. The Director of Nursing and the Administrator both confirmed that staff are educated monthly on privacy and that screens should be closed or minimized when unattended to protect residents' private medical records.
Failure to Conduct Required Assessments for Resident
Penalty
Summary
Facility staff failed to complete necessary cognitive and wound assessments for a resident who experienced an unwitnessed fall and had pressure ulcers. The facility's Falls Protocol Policy requires staff to conduct a comprehensive assessment, including cognitive evaluation, following a fall. However, after the resident was found on the floor attempting to transfer from bed to wheelchair, staff did not perform the required 72-hour neurological checks. Interviews with the RN and administrator revealed a lack of awareness as to why these assessments were not completed, despite the expectation that the facility's fall protocol be followed. Additionally, the facility's Pressure Ulcer and Injury Prevention and Management policy mandates weekly wound assessments, including detailed documentation of the ulcer's characteristics. Despite this, the resident's medical records lacked documentation of essential wound details such as stage, measurements, and tissue type for pressure ulcers on the coccyx and left lower extremity. Interviews with the administrator and RN indicated that the nurses were responsible for these assessments, yet they were not conducted as per protocol, and the reason for this oversight was unknown.
Failure to Notify Physician and Representative of Fall and Room Change
Penalty
Summary
Facility staff failed to notify a resident's physician or representative in a timely manner of an unwitnessed fall and a room change. The resident, who was moderately cognitively impaired and had a history of hip fracture and anticoagulant use, experienced an unwitnessed fall during the night. The fall was discovered the next morning when the resident complained of eye pain and was found with a bloodshot eye and broken glasses. The resident's representative was not informed of the fall until they visited the resident and requested an emergency room evaluation due to increased pain. Additionally, the resident was moved to a private room due to COVID-19 without proper notification to the resident's representative. The facility's policies require that both the physician and the resident's representative be informed of falls and room changes, but these notifications were not documented or communicated as required. Interviews with staff revealed inconsistencies in the notification process, with responsibilities for informing the resident's representative being unclear and not consistently followed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Heisinger Bluffs Rehab And Healthcare Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Stonebridge Villa Marie | 1.1 mi | ★★★★★ | 0 | 0 |
| Stonebridge Adams Street | 1.6 mi | ★★★★★ | 6 | 0 |
| Capitol River Wellness & Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Jefferson City Manor Care Center | 2.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.