Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Jefferson City Manor Care Center during CMS and state inspections, most recent first.
Facility staff did not complete or properly review the required annual facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. Policy required an interdisciplinary team, including the administrator, governing body representative, medical director, DON, infection preventionist, and multiple department directors, to conduct and annually update this assessment and have it reviewed by the QAA/QAPI team. Record review showed the assessment had not been reviewed by QAA/QAPI for over a year despite an active census, and the administrator acknowledged that no full annual facility assessment had been completed since assuming the role and that the due date for the annual assessment was not known.
Staff failed to follow infection control practices during blood glucose testing for three residents with diabetes. An LPN and a CMT repeatedly placed a shared glucometer and blood sugar supplies directly on medication carts, bedside tables, and a bed without a protective barrier, did not consistently perform hand hygiene between glove changes or after contact with blood, and did not disinfect the multi-use glucometer according to manufacturer instructions, instead wiping it with alcohol pads. Both staff members acknowledged not knowing or not following the manufacturer’s disinfection procedures or the expectation to use a protective barrier, while leadership stated that staff were expected to use proper hand hygiene, place supplies on a clean surface or barrier, and disinfect the glucometer with the designated wipes between residents.
Facility staff did not complete a required baseline care plan within 48 hours of admission for a resident, despite a policy mandating development of a baseline plan of care within that timeframe to address immediate needs. Documentation showed the resident’s baseline care plan was submitted several days after admission. The Administrator confirmed the care plan was late and that it should have been completed within 48 hours, and reported that the full‑time MDS/care plan nurse had been reassigned to floor duties due to short staffing. The MDS Coordinator reported being pulled to work as an RN and experiencing an influx of admissions, which led to falling behind on care plan completion.
Staff failed to develop a comprehensive, person-centered care plan for a resident who was cognitively intact and had diagnoses including anxiety, cardiac arrhythmia, vitamin deficiency, and pain. The only documented care plan focus was smoking, noting that the resident could smoke unsupervised and should avoid injury from unsafe smoking practices, with no care plan entries for ADLs, behaviors, or medical diagnoses. The administrator and MDS Coordinator acknowledged that the care plan should have been more complete and reported that the MDS nurse had been pulled to work as an RN on the floor, contributing to delays and backlogs in care plan development.
Facility staff failed to notify a physician and a resident’s responsible party after an allegation that a CNA slapped the resident on the leg during care. Policy required prompt notification of the physician and resident representative for changes in condition or status, including such incidents. The resident had severe cognitive impairment, non-Alzheimer’s dementia, depression, daily rejection of care, and was always incontinent. Progress notes contained no documentation of any notification, the family member reported learning of the allegation only during a later visit, and the NP confirmed not receiving any call about the incident.
A resident with severe cognitive impairment, dementia, depression, incontinence, and a history of physical aggression during ADLs was slapped multiple times on the leg by a CNA during incontinence care. The facility’s abuse prevention policy required measures to prevent and identify abuse, yet an NA reported hearing forceful smacking sounds from the hallway and observed the CNA striking the resident’s thigh with an open hand several times after the resident hit the CNA. The roommate reported hearing the incident behind a closed curtain, and facility documentation confirmed the allegation was substantiated, although the event was not documented in the resident’s progress notes.
A resident with Alzheimer's Disease and a history of wandering did not have a required wanderguard device in place for an extended period, despite repeated documentation by staff. The device was not replaced or reported to the DON or administrator, and the resident ultimately left the facility unnoticed, returning with an abrasion and without the wanderguard.
Staff failed to document and possibly administer physician-ordered wound treatments for two residents, as evidenced by missing entries on the Treatment Administration Record and resident reports of missed care. The DON and administrator confirmed that documentation was expected for all treatments or refusals, and that missing documentation likely meant treatments were not completed.
A resident with a signed DNR form and care plan indicating DNR did not have their code status consistently documented in all medical records. When the resident was found unresponsive, staff were uncertain of the code status and initiated CPR until the DNR was discovered. Staff interviews revealed a lack of awareness and use of the facility's code status identification systems, leading to the failure to honor the resident's advance directive.
Staff did not consistently provide or document nail care, facial hair grooming, or hair brushing for four residents who required assistance with ADLs. Observations found long nails with debris, untrimmed facial hair, and unkempt hair, despite care plans and facility policy requiring these services. Interviews with CNAs, an LPN, and nursing leadership confirmed the expectation for regular hygiene care, but acknowledged lapses in practice and documentation.
Staff failed to update and implement comprehensive, person-centered care plans for three residents, as required by federal regulations and facility policy. Care plans were not revised in conjunction with quarterly MDS assessments, resulting in outdated documentation that did not reflect current care needs, medication regimens, or required interventions. Interviews with the MDS Coordinator, DON, and Administrator confirmed lapses in care plan updates and ongoing efforts to address the issue.
Facility staff failed to protect residents' medical information, leaving sensitive documents face up on nurse station desks in public areas. Observations showed that report sheets with private details were visible to residents and visitors. Interviews with LPNs and the DON confirmed the breach of protocol, acknowledging that such documents should be covered or turned over to ensure privacy.
Two residents reported missing money and a wallet, but the LTC facility staff failed to report these allegations to the state as required by law. Despite being aware of the incidents, the administrator and other staff members did not fulfill their mandated reporting obligations, citing personal judgment over policy compliance.
A resident with stage three pressure ulcers did not have their wound treatments documented as administered according to physician orders. The resident reported inconsistent dressing changes by the night shift, leading to closely spaced changes by the day shift. The DON acknowledged gaps in documentation and lack of follow-up, while the administrator confirmed that undocumented treatments were assumed not done.
Facility staff failed to ensure safe medication storage and monitoring, as evidenced by an unlocked medication cart left unattended and a resident's medications left out in a community area. A CMT forgot to lock the cart, and a resident's inhaler and nasal spray were left unattended, with multiple residents present. The DON and administrator confirmed that medications should be secured to prevent unauthorized access.
The facility failed to store food properly, leading to potential contamination and outdated use. Observations revealed improperly labeled and dated food items in refrigerators and freezers. The kitchen equipment and surfaces were unsanitary, with grease and food debris accumulation. Additionally, food was served at unsafe temperatures, and ice machines lacked proper drainage, risking cross-contamination. The administrator, acting as dietary manager, acknowledged these issues, noting the kitchen staff's need for training.
The facility did not have an RN on duty for at least eight consecutive hours per day, seven days a week, as required. The absence of RNs on multiple weekends in March, April, and May 2024 was confirmed by the RN staff schedule. The DON was unaware that the eight hours needed to be consecutive, and the Administrator cited staffing shortages as the reason for the gaps, despite ongoing hiring efforts.
Facility staff failed to properly store and label medications, with multiple medication carts containing opened and undated bottles, some of which were expired. Interviews with staff, including a CMT, LPN, DON, and the administrator, revealed a lack of adherence to the facility's medication management policy, which requires checking expiration dates and labeling open dates on multi-dose containers.
Facility staff failed to document collaboration with hospice providers for two residents receiving hospice care, as required by the facility's agreement. Reviews of the hospice binder and medical records showed no coordinated plan of care. Interviews with an LPN, the DON, and the Administrator confirmed the absence of documentation, despite expectations for proper communication and record-keeping.
Failure to Complete and Review Required Annual Facility-Wide Assessment
Penalty
Summary
Facility staff failed to conduct and document an annual facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies, as required by facility policy. The written policy, revised in October 2018, required that once a year, and as needed, a designated interdisciplinary team (including the administrator, a governing body representative, medical director, DON, infection preventionist, and department directors for environmental services, physical operations, dietary, social services, activities, and rehab) conduct a facility-wide assessment to ensure resources were available to meet residents’ specific needs. Record review showed the facility assessment, last updated on 4/7/26, had not been reviewed by the QAA/QAPI team since February 2025, despite a current census of 70. During interview, the administrator stated that he/she had not updated the facility assessment on 4/7/26, had not completed a full annual facility assessment since assuming the role in September 2025, and did not know when the annual assessment was due, estimating it was probably due in February 2026 and acknowledging it was not completed. No specific resident medical histories or conditions were described in relation to this deficiency.
Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Blood Glucose Testing
Penalty
Summary
Facility staff failed to follow infection prevention and control practices during blood glucose monitoring for three residents with diabetes. The facility’s hand hygiene policy required staff to perform handwashing or use alcohol-based hand rub before and after resident contact and after contact with blood or body fluids, and the glucometer policy required cleaning and disinfection between residents per manufacturer instructions. The manufacturer’s directions specified a multi-step cleaning and disinfection process using appropriate towelettes after each patient use. The facility’s fingerstick glucose policy also required use of clean gloves, cleaning and disinfecting reusable equipment between uses, and handwashing after glove removal, but did not address use of a protective barrier under the glucometer and supplies. For one resident with moderate cognitive impairment and diabetes, an LPN removed the glucometer from the medication cart, placed it directly on the cart without a protective barrier, entered the room without performing hand hygiene, and applied gloves. After checking the resident’s blood sugar, the LPN again placed the glucometer directly on the cart without a barrier, did not sanitize the glucometer, and returned it to the basket with other blood sugar supplies. For another resident with severe cognitive impairment and diabetes, the same LPN placed the glucometer, alcohol pad, and lancet directly on the bedside table without a barrier, attempted a blood sugar check, then removed gloves and donned new gloves without hand hygiene. The LPN placed new supplies on the resident’s bed, used a lancet to obtain blood, used a gloved finger to wipe excess blood from the resident’s finger, removed one glove used to wipe the blood, placed the glucometer on the bed, then picked it up with an ungloved hand, left the room, placed the glucometer directly on the medication cart, handled medications without hand hygiene, and wiped the glucometer with an alcohol pad instead of the disinfectant wipes specified by the facility. For a third resident with intact cognition and diabetes, a CMT exited a resident’s room with the glucometer and placed it directly on the medication cart, inserted a new strip, and laid the alcohol pad and lancet on the cart without a protective barrier. The CMT then entered the resident’s room to obtain the blood sugar, exited, and again placed the glucometer directly on the medication cart without a barrier, wiping it only with an alcohol pad before returning it to the cart. In interviews, the LPN stated he/she used alcohol pads between residents, believed the facility wanted use of purple disinfectant wipes but was afraid to use them without gloves, did not know the manufacturer’s disinfection instructions, and acknowledged missing hand hygiene opportunities and the potential to spread blood-borne illness. The CMT reported using alcohol wipes to sanitize the glucometer, was unaware of the manufacturer’s instructions, and stated he/she had never been trained to use a protective barrier under the glucometer or supplies. The administrator and DON both stated that supplies should be placed on a clean surface or protective barrier, that staff were expected to perform hand hygiene at specified points during blood sugar testing, and that staff were to follow manufacturer instructions and use the purple-tub disinfectant wipes, noting that alcohol wipes were not sufficient to disinfect the glucometer.
Baseline Care Plan Not Completed Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to complete a baseline care plan assessment within 48 hours of admission for one sampled resident, contrary to the facility’s Baseline Care Plan policy revised December 2016, which requires development of a baseline plan of care to meet the resident’s immediate needs within forty‑eight hours of admission. Record review showed the resident’s face sheet documented an admission date, but the corresponding baseline care plan, although reflecting the same admission date, was not submitted until 3/15/26, exceeding the required 48‑hour timeframe. During interviews, the Administrator acknowledged not realizing the baseline care plan was late and confirmed that baseline care plans should be completed within forty‑eight hours, noting that the full‑time MDS and care plan staff member had been pulled to work as a floor nurse due to short staffing. In a separate interview, the MDS Coordinator stated that being reassigned to work as an RN on the floor and an influx of admissions during that period caused them to fall behind on care plans.
Failure to Develop Comprehensive Person-Centered Care Plan for a Resident
Penalty
Summary
Facility staff failed to develop and implement an individualized, comprehensive, person-centered care plan for one resident, as required by facility policy. The facility’s Care Plan Comprehensive Person-Centered Policy, revised December 2016, requires that each resident have a comprehensive care plan with measurable objectives, timeframes, and descriptions of services to meet physical, psychosocial, and functional needs, including resident goals, expressed wishes, and treatment refusals. Surveyor review of the resident’s record showed that the resident had been assessed on the MDS as cognitively intact and diagnosed with anxiety, cardiac arrhythmia, vitamin deficiency, and pain. Despite these identified conditions and needs, the resident’s care plan, last reviewed on 4/7/26, only addressed smoking, stating that the resident is a smoker, can smoke unsupervised, and that the goal is for the resident not to suffer injury from unsafe smoking practices. Record review further showed that the resident’s care plan lacked documentation in all other required care areas, including ADLs, behaviors, and diagnoses, contrary to the facility’s stated care planning process. During interviews, the administrator acknowledged that the resident should have a much more comprehensive care plan than just smoking instructions and reported that the full-time MDS and care plan staff had been pulled to work as a floor nurse due to short staffing. The MDS Coordinator confirmed being pulled to work as an RN on the floor, which caused delays and backlogs in care plan completion, and noted that usual care plan content for most residents includes code status, activities, diagnoses, behaviors, BIMS, Braden assessment, and ADLs, updated quarterly or as needed. These interviews and record reviews demonstrated that the required comprehensive care plan for this resident was not developed beyond the smoking focus.
Failure to Notify Physician and Family After Alleged Staff-to-Resident Abuse
Penalty
Summary
Facility staff failed to notify the physician and the resident’s responsible party after an allegation of staff-to-resident abuse. The facility’s policy on “Change in a Resident’s Condition or Status,” revised February 2021, required prompt notification of the physician and resident representative for changes in the resident’s medical or mental condition and/or status. A certified nursing assistant (CNA) was alleged to have slapped a resident on the leg while providing care. Review of the resident’s progress notes from 1/27/26 to 2/4/26 showed no documentation that the physician or family had been notified of this allegation. The administrator stated that he/she expected the physician and family to be notified when there are allegations of employee-to-resident abuse but could not locate any progress note or incident report documentation showing that such notifications occurred. The resident involved had a Significant Change MDS dated 12/09/25 indicating severe cognitive impairment, daily rejection of care, complete bowel and bladder incontinence, and diagnoses of non-Alzheimer’s dementia and depression. During interview, the resident’s family member reported that facility staff did not notify him/her about the abuse allegation and that he/she only learned of it the following day during a visit, when the administrator asked if he/she knew about the incident. In a separate interview, the nurse practitioner confirmed having no record of, and not receiving, any call from the facility regarding the CNA slapping the resident during care. These findings demonstrate that required notifications to the physician and resident representative were not made or documented following the abuse allegation.
Failure to Prevent Physical Abuse During Provision of Care
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a CNA slapped the resident on the leg during care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program and Clinical Protocol policy, revised April 2021, stated the facility would develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. An investigation dated 1/28/26 documented that staff notified the administrator that a nurse assistant had witnessed a CNA hit a resident on the leg five times, and witness statements and resident interviews were collected. The investigation concluded the allegation was substantiated. The resident involved had a Significant Change MDS dated 12/09/25 showing severe cognitive impairment, daily rejection of care, and diagnoses including non-Alzheimer’s dementia and depression, with the resident always incontinent of bowel and bladder. The resident’s care plan, dated 04/08/24, identified impaired cognitive function/dementia or impaired thought process, ADL self-care performance deficit, physical aggression, and bowel and bladder incontinence. Progress notes from 1/24/26 to 1/28/26 did not contain documentation that the CNA slapped the resident on the leg while providing care. Interviews provided further detail of the incident. The resident’s roommate reported not seeing the event due to the curtain being closed but stated he/she could hear it. The CNA involved stated that while helping the resident to bed, the resident resisted care, the brief was soaked with urine, and the CNA was working alone; the CNA denied ever hitting or slapping anyone and reported being surprised by the accusation. The administrator reported receiving a call from an RN that a nurse assistant had witnessed the CNA strike the resident five times on the leg while performing pedicare. The nurse assistant witness stated that while walking down the hall, he/she heard a smacking noise, looked into the room, and saw the resident hit the CNA and the CNA hit the resident on the outer part of the left thigh with an open hand, with a total of about five hits or slaps, and noted that although the resident was known to be a “fighter” during care, staff were not supposed to hit residents back.
Failure to Replace Wanderguard Results in Resident Elopement
Penalty
Summary
Facility staff failed to ensure that a resident identified as at risk for elopement consistently had a wanderguard device in place as ordered by the physician. The resident, who had a primary diagnosis of Alzheimer's Disease and a history of wandering and attempted elopements, was assessed as requiring a wanderguard on the left ankle. Despite this, staff documented on multiple occasions over several months that the resident did not have a wanderguard in place, with no documentation of replacement or explanation for its absence. The resident's care plan and physician orders required the wanderguard to be checked every shift and as needed. Progress notes repeatedly indicated the absence of the device, but there was no evidence that staff replaced the wanderguard or communicated the issue to the DON or administrator. Interviews revealed that some staff believed the resident was no longer a safety risk for elopement, while others did not follow up on the missing device, and the DON and administrator were not made aware of the ongoing issue until after the resident left the facility. The deficiency culminated when the resident left the facility without staff knowledge and was found by a community member sitting on a curb near the facility. The resident was returned to the facility with an abrasion and was not wearing a wanderguard at the time. Staff interviews confirmed a lack of consistent action to replace the missing device, despite repeated documentation of its absence and the resident's known risk factors.
Failure to Document and Administer Physician-Ordered Wound Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the administration of wound treatments as directed by physicians for two residents. For one resident, who was cognitively intact and had venous and arterial ulcers, physician orders required daily wound care on both lower legs. However, the Treatment Administration Record (TAR) lacked documentation of treatment or refusal on multiple specified dates. The Director of Nursing (DON) confirmed that refusals should be documented and that nurses are expected to record all treatments or refusals on the TAR. For another resident, also cognitively intact and receiving surgical wound care, physician orders required pin-site care every shift. The TAR did not contain documentation of wound treatment on several dates across two months. The resident reported that staff were not performing treatments every shift as ordered. The DON was unaware of any refusals and expected treatments to be administered as ordered. Interviews with staff and the administrator confirmed that missing documentation on the TAR likely indicated treatments were not completed, and that the DON was responsible for auditing and addressing missing documentation.
Failure to Honor DNR Status Due to Inconsistent Documentation and Staff Awareness
Penalty
Summary
Facility staff failed to obtain and document a timely advance directive for a resident who had elected Do Not Resuscitate (DNR) status. Despite the resident having a signed DNR form and the care plan indicating DNR, the Physician Order Sheet did not contain an order for the resident's code status or advanced directive. When the resident was found unresponsive, staff were uncertain of the code status and initiated CPR until the DNR status was discovered on the resident's facesheet. The code status was not consistently documented across all relevant records. Interviews revealed that code statuses were supposed to be indicated by colored stickers on residents' doors and maintained in a binder at the nurses' station, but staff involved were either unaware of these systems or did not check them before acting. The LPN who initiated CPR was not aware of the resident's code status and was not familiar with the location of the code status documentation. Both the DON and the administrator confirmed the existence of these systems but could not explain why staff failed to follow the resident's wishes.
Failure to Provide Required Hygiene Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate care to meet the hygiene needs of four residents who required assistance with activities of daily living (ADLs), specifically in the areas of nail care, facial hair grooming, and hair brushing. According to the facility's own policy, residents unable to independently perform ADLs should receive necessary support to maintain personal hygiene, including nail and facial hair care. However, review of care plans, shower sheets, and direct observations revealed that staff did not consistently document or provide these services as required. For example, one resident with severe cognitive impairment and another with a contracted hand both had long nails with debris and untrimmed facial hair, despite care plans indicating the need for staff assistance. Another resident, who was cognitively intact but required setup or cleanup help, reported that staff only trimmed nails upon request and sometimes the nails caused pain. A fourth resident, also with severe cognitive impairment, was observed with unkempt hair, long nails with debris, and un-groomed facial hair, and confirmed that staff only occasionally provided grooming assistance. Interviews with CNAs, an LPN, the ADON, and the administrator confirmed that nail care and facial hair assistance were expected on shower days and as needed, and that staff were directed to brush residents' hair in the mornings. Staff acknowledged that failure to provide these services could lead to infection control concerns and was not dignified for residents. Despite these expectations, documentation and observations showed that the required hygiene care was not consistently provided to the affected residents.
Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by federal regulations and the facility's own policies. Specifically, care plans were not updated in conjunction with the Minimum Data Set (MDS) assessments, which are mandated to occur at least quarterly. For one resident, the care plan was not updated to reflect the most recent MDS assessment, despite significant care needs including cognitive status, use of multiple medications, dependence on staff for mobility and personal care, and use of oxygen therapy. Another resident's care plan was not updated to include activities of daily living (ADL) or specific anticoagulant medication information following an assessment. A third resident's care plan also lacked updates after a quarterly MDS assessment, despite changes in their care needs and medication regimen. Interviews with facility staff, including the MDS Coordinator, Administrator, and DON, confirmed that the responsibility for updating and revising care plans on a quarterly and annual basis was understood, but not consistently executed. The MDS Coordinator acknowledged being new to the position and working to address the backlog of care plan updates. The Administrator and DON both stated that care plans should be reviewed weekly and updated according to guidelines, and noted that additional staff had been hired to assist with this process. Despite these acknowledgments, the care plans for the sampled residents remained outdated, failing to reflect current assessments and interventions necessary to meet individual resident needs.
Failure to Protect Residents' Medical Information
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information, as observed during a survey. Medical information for six residents was found face up on the nurse station desks, which were located in a public area visible to other residents and visitors. The facility's policy on confidentiality, dated October 2017, mandates that access to residents' personal and medical records be limited to authorized staff and business associates. However, observations on multiple occasions showed that resident report sheets containing sensitive information such as code status, date of birth, allergies, and diagnoses were left unattended and visible to the public. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed an acknowledgment of the breach in protocol. LPNs admitted that the report sheets and physician notes should not have been left face up, and the DON confirmed that staff are expected to keep such documents covered or turned over to protect residents' privacy. The administrator also stated that medical information should not be accessible to the public and should be properly secured. Despite these expectations, the failure to adhere to the facility's confidentiality policy resulted in a violation of residents' privacy rights.
Failure to Report Allegations of Misappropriation
Penalty
Summary
The facility staff failed to report allegations of misappropriation of money for two residents in accordance with State law. The facility's policy on abuse and neglect mandates timely reporting of such incidents to appropriate agencies, but this was not adhered to. Resident #1, who was assessed with moderate cognitive impairment, reported missing money shortly after admission. Despite multiple staff members, including the Maintenance Director, Therapy Director, and Social Services Designee (SSD), being aware of the allegation, it was not reported to the state. The administrator was informed but did not report the incident, believing the resident's inconsistent statements about the amount of money did not warrant it. Resident #5, assessed as cognitively intact, reported a missing wallet on the first night at the facility. The wallet was later found in a locked housekeeping supply closet, wrapped in a paper towel, suggesting it had been hidden. The Maintenance Director and housekeeper discovered the wallet, and it was returned to the resident. Despite the suspicious circumstances, the administrator did not report the incident to the state, as they did not believe it rose to the level of reportable theft. The Director of Nursing (DON) and SSD were aware of the incident but did not ensure it was reported. The facility's failure to report these incidents highlights a significant deficiency in adhering to mandated reporting requirements. The administrator's decision not to report was based on personal judgment rather than policy compliance, and other staff members, despite being mandated reporters, did not fulfill their obligations. This lack of action contravenes the facility's policy and state law, which require timely reporting of suspected abuse, neglect, or theft to appropriate authorities.
Failure to Document Wound Treatment Administration
Penalty
Summary
The facility staff failed to document the provision of physician-ordered wound treatments for a resident with three stage three pressure ulcers. The resident, who was cognitively intact and did not refuse care, had a care plan that required daily application of a wet to dry topical antiseptic dressing to the sacral wound. The physician's order specified that the dressing should be changed twice a day, approximately 12 hours apart. However, the Treatment Administration Record (TAR) showed missing documentation for the dressing changes on specific dates and times, indicating that the treatments may not have been administered as ordered. Interviews revealed that the resident expressed concerns about the night shift's failure to change the dressing or doing so at inappropriate times, leading to closely spaced dressing changes by the day shift. The Director of Nursing (DON), who also served as the facility wound nurse, acknowledged the gaps in the TAR and admitted to not following up adequately on the shift reports or checking the TARs regularly. The administrator confirmed that if the dressing change was not documented, it was assumed not to have been done, and the DON should have investigated the missing documentation.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to ensure medications were monitored and stored safely, as evidenced by two separate incidents. In the first incident, an unlocked medication cart was left unattended on the rehabilitation hall, allowing a resident in a wheelchair to pass by it. The Certified Medication Technician (CMT) admitted to forgetting to lock the cart after administering medication and leaving the area to check on showers. Both the Director of Nursing (DON) and the administrator confirmed that the medication cart should have been locked when unattended to prevent residents from accessing medications that are not theirs. In the second incident, a resident's inhaler and nasal spray were left unattended on a table in the community area, with multiple residents present and no staff supervision. The resident mentioned that the CMT was supposed to return for the medications but did not. The Licensed Practical Nurse (LPN) was unaware of the unattended medications and acknowledged that they should not be left out, as residents could mistakenly ingest them. The DON and the administrator reiterated that medications should not be left unattended, even if the resident is alert, to prevent other residents, especially those with memory issues, from accessing them.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to store food properly, leading to potential contamination and outdated use. Observations revealed that the reach-in refrigerator contained items such as a plastic pour container labeled as Italian with a use-by date of 5/20/24 and a container labeled as ham dated 5/12/24. The reach-in freezer had unlabeled and undated bags of breaded meat, sausage dated 5/7/24, fish dated 5/17/24, and taco meat with a use-by date of 6/01. The walk-in freezer contained open and undated bags of beef, a green tube of meat loosely covered with foil, and other items without proper labeling or dating. Additionally, the cooks' prep refrigerator contained tortillas dated 3/17 with a use-by date of 4/19 and unlabeled containers of pancake batter and French toast mix. The facility also failed to maintain kitchen equipment and surfaces in a sanitary manner. Observations showed an accumulation of grease and food debris around the range hood filters, walls near the deep fryer, and the meat slicer. A heavily soiled towel was found under the cooks' prep refrigerator. The facility lacked policies for kitchen cleanliness and equipment cleaning, contributing to these unsanitary conditions. Furthermore, the facility did not ensure food was served at safe temperatures, with scrambled eggs held at 96°F, sausage at 100°F, and gravy at 126°F, all below the recommended 135°F. The ice machines in the main dining and activity rooms lacked an air gap in the drain, risking cross-contamination. The maintenance director was unaware of the air gap requirement and had overlooked filter replacements. The administrator, acting as dietary manager, acknowledged the issues but noted the kitchen staff was new and in need of training.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight hours per day, seven days a week, as required. The facility, with a census of 72, did not have an RN on duty on multiple weekends in March, April, and May 2024. The facility's policies did not include a policy for RN coverage, and the RN staff schedule confirmed the absence of an RN on specific dates. During interviews, the Director of Nursing (DON) acknowledged awareness of the requirement but was unaware that the eight hours needed to be consecutive. The Administrator also recognized the requirement but cited staffing shortages as the reason for the gaps in the schedule, despite efforts to hire additional RNs.
Medication Storage and Labeling Deficiency
Penalty
Summary
Facility staff failed to store and label medications properly, as observed during a survey. The survey revealed that multiple medication carts contained bottles of medications that were opened and undated, including fish oil, acetaminophen, omeprazole, ibuprofen, magnesium oxide, ferrous sulfate, calcium, senna, melatonin, potassium chloride, and milk of magnesia. Some of these medications were also expired, such as a bottle of ferrous sulfate with an expiration date of January 2024 and a bottle of senna with an expiration date of April 2024. The facility's policy requires that the expiration or beyond-use date on the medication label be checked prior to administering and that the date opened be recorded on multi-dose containers. Interviews with facility staff, including a certified medication technician (CMT), a licensed practical nurse (LPN), the Director of Nursing (DON), and the administrator, revealed a lack of adherence to the facility's medication management policy. The CMT admitted to overlooking some medications and had not yet checked the 300 hall cart. The LPN and DON both stated that it is the responsibility of the CMTs to maintain medication carts, including checking for expired medications and ensuring open dates are labeled. The administrator also expected the DON to monitor staff compliance with these procedures. Despite these expectations, the medication carts were found to contain expired medications and bottles without open dates, indicating a failure in the facility's medication management practices.
Lack of Coordinated Care Documentation for Hospice Residents
Penalty
Summary
The facility staff failed to document collaboration of care with hospice providers for the development and implementation of a coordinated plan of care for two residents receiving hospice services. The facility's Nursing Facility Hospice and Respite Care Services Agreement requires that hospice develop a Plan of Care at the time of admission and update it at least every 15 days. However, reviews of the facility's hospice binder and the residents' medical records revealed a lack of documentation of a coordinated plan of care between the facility and the hospice provider for both residents. This deficiency was identified during a survey of the facility, which had a census of 72 residents. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed the absence of necessary documentation. The LPN indicated that hospice communication should be documented in a binder at the nurse's station, but was unsure why it was missing. The Director of Nursing and the Administrator both expressed expectations for communication and documentation between the hospice provider and the facility, acknowledging that they were unaware of the missing documentation in the residents' medical records.
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 47 citations issued within 25 miles in the last 12 months — 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) |
|---|---|---|---|---|
| Capitol River Wellness & Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Stonebridge Villa Marie | 1.4 mi | ★★★★★ | 0 | 0 |
| Stonebridge Adams Street | 1.8 mi | ★★★★★ | 6 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 2.4 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 2.4 mi | ★★★★★ | 0 | 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.