Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 South County Health Care Center during CMS and state inspections, most recent first.
Unsafe Food Storage and Unsanitary Dietary Area: The dietary area had debris, personal items, and unclean surfaces on counters, carts, and the floor, including opened drink containers, paper clips, a penny, hair, and uncapped thermometers near food service items. The refrigerator and freezer contained multiple unlabeled or undated food items and expired products, and the stove and backsplash had heavy grease, grime, and food splatter; the DM reported using first in/first out and marking food by arrival and expiration dates.
Insufficient surety bond for resident trust funds. Review of the Resident Trust policy and resident account records showed the average monthly resident trust balance required a bond of at least $61,500, but the facility’s current bond was only $50,000. The Administrator acknowledged the bond should equal one-and-one-half times the resident trust balance and said corporate was increasing the bond.
Unsafe and Unsanitary Resident Environment: The facility failed to maintain a clean, comfortable, and homelike environment. A resident room had dark water in the sink, staining, rust, and a mattress with black grime and stains, while hall floors were sticky and multiple shower rooms and a restroom had black grimy buildup, brown debris, broken or missing tiles, damaged shower equipment, worn privacy curtains, and soiled items on the floor. Residents reported dirty shower rooms, overflowing trash, and fear of using a shower room because the floor was busted up.
Failure to complete required pre-employment background checks was cited after record review showed multiple employees did not have CBC, EDL, and/or NA registry checks completed before hire, despite facility policy requiring screening prior to employment. The Administrator and DON stated they would expect all employees to have CBC/EDL and NA registry checks completed before hire, and the Administrator noted NA registry checks were only done for CNAs and CMTs through TMU.
A facility failed to keep residents’ code status documentation consistent across the chart, POS, and care plans for four sampled residents. Records showed conflicting Full Code and DNR information, missing code status entries in the electronic charting system and POS, and absent signed documentation for one resident. Staff stated code statuses should be documented in the EMR and at the nurse’s station, and the DON and Administrator said they expected consistent chart documentation.
Incomplete discharge documentation for a resident with behavioral concerns. The facility failed to complete a discharge recapitulation and failed to document the physician’s reason for discharge for a resident with dementia, Parkinson’s disease, Alzheimer’s disease, disorientation, and bipolar disorder. The record showed an unsigned, undated, incomplete discharge recapitulation citing inappropriate behaviors and elopement risk, no discharge notes, and an MDS that listed discharge to hospital with return anticipated. The Administrator said the resident had been exit seeking and had frightened another resident, but there was no documentation of that decision.
Missing transfer notices, bed-hold documentation, and discharge summary: The facility did not provide written transfer/bed-hold notification to several residents or their representatives when residents were sent to the hospital, and it failed to complete a discharge summary with a recapitulation of stay for one resident discharged home after therapy goals were met. The DON stated that some transfer and bed-hold paperwork had not been completed, and staff were unsure who was responsible for these documents after the ownership change.
A facility failed to complete accurate MDS assessments for multiple residents. One resident was coded as having a tracheostomy despite no trach being present, another was coded as not using oxygen despite having a CPAP in the room, a third was coded as having no indwelling device despite a urinary catheter and leg bag, and another was coded as not receiving oxygen despite being observed on 2 L NC. A discharge record for one resident was also inconsistent and incomplete, with conflicting documentation about the discharge destination and reason.
Care plans and orders did not match the actual needs and treatments of four residents. One resident used CPAP nightly, one had a urinary catheter with no catheter care orders, one was observed on O2 despite no O2 orders or care plan entry, and one used a half side rail that was not addressed in the care plan or orders. Interviews and record review showed the care plans were not updated to reflect these resident-specific interventions.
A resident with a urinary catheter was observed with a leg bag, but the chart had no physician orders for the catheter or catheter care and the care plan did not address the device. The resident said staff would not remove the catheter without an order and that staff did not clean it, while the DON confirmed there were no orders and noted the resident had frequent urinary tract pain and frequent UTIs.
Missing CPAP and Oxygen Orders: The facility failed to have orders for a resident's CPAP settings, cleaning, and tubing changes, and failed to have a physician order prior to oxygen use for another resident. One resident was observed using CPAP nightly without orders for settings or maintenance, while another resident was observed on O2 at 2 L/min via NC with tubing changes that were not fully supported by orders or care plan documentation.
Failure to Assess and Obtain Consent for Bed Rail Use: The facility did not complete entrapment assessments or obtain signed informed consent before using half bed rails for multiple residents. Residents with diagnoses including abnormal posture, encephalopathy, dementia, psychosis, schizophrenia, and COPD were observed with bed rails in place, while records lacked documentation of risks/benefits review and, in some cases, the residents said they did not use the rail or were unsure why it was there. One resident’s rail was observed wobbling with a visible gap between the rail, mattress, and bed frame.
Medication error rate exceeded the allowed threshold when a CMT administered Humalog insulin to two residents without priming the insulin pen with two units as required by policy and manufacturer directions. Surveyors observed three insulin administration errors, resulting in an 11.11% error rate; the CMT stated he/she did not know insulin pens had to be primed, and the DON and Administrator said they would expect priming before insulin administration.
Food was served at improper temperatures and was described as unpalatable and poorly prepared. Meal observations showed multiple items, including fruit, sandwiches, pasta, slaw, quesadilla, rice, meatballs, potatoes, green beans, and peaches, were below required hot or cold holding standards, and some items were dry or unattractive. Residents reported the food was cold, bland, tough, questionable, and served in small portions, and the DON and Administrator stated food should be palatable and within the proper temperature range.
A resident with a Foley catheter and a buttock wound received peri care, Foley care, and wound care without proper infection control. A CNA entered without gown or gloves and repeatedly handled the resident’s peri area, catheter, and incontinent care without changing gloves or performing hand hygiene between tasks. An LPN also entered without a gown for EBP, did not sanitize the bedside table before placing supplies on it, and performed wound and peri care while changing gloves without hand hygiene between steps; the LPN stated he/she had never heard of EBP.
Facility staff failed to complete regular inspections of bed frames, mattresses, side rails, and enabler bars for four residents. Two residents had no maintenance inspection in the record and were observed with half rails in use, and one resident’s half rail wobbled with an approximately 6-inch gap between the rail and mattress while the bed frame was larger than the mattress. The Administrator and DON acknowledged that an assessment to confirm proper fit had not been done.
The facility failed to provide required annual dementia care competency training for three sampled CNAs. Record review showed each CNA completed annual in-services, but none had documented dementia care training, and the facility did not have a policy for required nurse aide training. The DON said staff complete a January packet and monthly online trainings, but was unsure what trainings applied, how completion was tracked, and what mandatory trainings were required.
A facility failed to make survey results and any plan of correction readily accessible to residents and visitors. Observations found no survey binder in the reception/entry area, and the Receptionist said the results were kept in a folder on the desk and resident copies were in the activities room, with no posting of availability observed. The Administrator and DON stated they would expect the survey results to be available for residents and family members.
Nurse staffing data was not posted in a clear, readable, and readily accessible location for residents and visitors. The facility’s policy required the Nurse Staffing Sheet to be posted at the beginning of each shift with census and staffing hours, but observations showed it was not posted. The DON stated the forms were filled out and somewhere on his/her desk, and the Administrator and DON said staffing should be posted daily.
Two residents did not receive multiple doses of prescribed medications, including IV antibiotics and antihypertensives, due to medication unavailability following a pharmacy change. Staff interviews confirmed delays in medication delivery and inadequate emergency supplies, resulting in missed treatments and lack of documentation during the transition.
The facility failed to maintain sanitary conditions in food storage and preparation areas, risking cross-contamination and food-borne illness. Observations showed unlabeled food items, dirty floors, and incomplete temperature logs. A dietary aide prepared food without gloves, and dented cans and opened bags were found in storage. The Dietary Manager and staff acknowledged the need for cleanliness and proper food handling.
The facility failed to ensure privacy for residents during showers by not providing a shower curtain in the 100 hall shower room, affecting three residents. Observations showed the lack of a curtain and no indication of room occupancy. Residents expressed discomfort and embarrassment, with some reducing shower frequency. The Administrator removed the curtain due to safety concerns but did not implement a solution for independent residents.
A facility failed to follow proper infection control techniques during medication administration. A CMT did not wash or sanitize hands before or after administering medications to several residents, handled medication cups with bare hands, and failed to change gloves or perform hand hygiene after handling medication carts and administering eye drops. The facility's leadership expected staff to adhere to hand hygiene protocols.
Unsafe Food Storage and Unsanitary Dietary Area
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, with observations showing debris, personal items, and unclean surfaces throughout the dietary area. On 08/04/25, the coffee counter had debris, opened sweetener packets, and an opened water bottle; a work shelf and counter had a fragment of foil and two empty soda bottles next to trays of clean coffee mugs; and a three-tiered cart had debris and a personal reusable drinking cup with a straw and lid. Later observations showed the prep counter with debris, ink pen lids, and paper clips, and a tray with four paper-wrapped straws, a penny, a strand of hair, and three thermometers with no caps. The cereal/utensil counter also had cereal debris, sweetener packets, paper clips, and wadded paper, while the floor had debris, sweetener packets, and salt/pepper packets. Food storage issues were also observed in the refrigerator and freezer. The refrigerator contained multiple cartons of apple juice with no dates, opened cheese slices not labeled or dated, unopened sliced cheese packages with no expiration dates, unopened shredded cheese packages with a package date but no expiration date, an opened bag of shredded cheese with no date, and several unopened packages of shredded cabbage and carrots with best-if-used-by dates of 07/24/25 and 07/23/25. The freezer contained an opened bag of hash rounds with no label or expiration date, unopened bags of frozen diced potatoes with an expiration date of 07/05/25, and unopened bags of frozen diced peppers and onions with expiration dates of 09/30/24. The stove had black grease and grime, food particles, and thick brown/black splatter on the backsplash, and a metal tray cart next to the stove held a butter wrapper and a soiled knife. The DM stated he/she started in early July, had taken classes online, and used first in/first out, with food marked by arrival and expiration dates; the Administrator and DON stated they expected the kitchen, refrigerator, freezer, and food labeling to be clean and free of expired items.
Insufficient surety bond for resident trust funds
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was cited after review of the facility’s Resident Trust policy, resident trust account records, and current surety bond. The policy required the facility to provide financial security by means of a surety bond in an amount equal to at least one and one-half times the average total of the reconciled monthly balances, and to keep a current copy of the bond on file. Review of the residents’ personal funds account for July 2024 through July 2025 showed an average monthly balance of $40,973.07, which rounded to $41,000.00 and required a bond of at least $61,500.00. The facility’s current surety bond, effective 05/06/25, was $50,000.00, which was $11,500.00 below the required amount. During interview, the Administrator stated the bond should be one-and-one-half times the resident trust balance and said corporate was in the process of increasing the bond to $100,000.00.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment. Review of the facility policies showed that environmental rounds were to be completed daily by department heads and were to include resident rooms, drawers, bathrooms, and inspection for potentially hazardous items and areas not in compliance with state and federal guidelines. The facility’s Safe and Homelike Environment policy also required housekeeping and maintenance services to maintain a sanitary and comfortable environment, minimize odors, report furniture in disrepair, and address unresolved environmental concerns. Observation of a resident room showed an out-of-order sign on the mirror, a sink half-filled with dark brown water, staining around the sink, chipped paint and rust under the cabinet, and an unmade extra bed with a mattress that had black grime and stains. Hallway flooring on the 100-hall was observed to be sticky across its entire length on multiple occasions. A shower room on the 100-hall had dim lighting, brown debris and grime in the corners, black grimy buildup on shower floor grout, shower walls, and a wall shelf, orange-stained caulk, brown streaks on the floor, a toilet with brown substance under the lid and in the bowl, no toilet paper nearby, grimy toilet assist bars, and shower chairs that were taped together and in disrepair. Additional observations in the 100-hall shower room with tub showed dirt and debris in the tub, gloves, a shower chair, a broken-off water spigot lying in the tub, cracked and missing shower floor tiles, a shower head lying on the floor, worn privacy curtains with missing hooks and tied-up bottoms, and toilet items lying on the floor. Another shower room and the male restroom labeled 100-15 were also observed with black grimy substances, sticky floors, brown grime and stains, soiled linens and towels on the floor, and other unsanitary conditions. A section of wall in Room 124 had two broken pieces of tile by the entryway. One resident said he/she was afraid to use the shower room because the floor was busted up, and another resident said the shower rooms were dirty, soap dispensers were not filled, and trash cans were full and overflowing.
Failure to Complete Required Pre-Employment Background Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interviews showed the facility did not ensure required pre-employment background checks were completed before hire for six of ten sampled employees. The missing or delayed checks included the Certified Background Check (CBC), Employee Disqualification List (EDL), and Nurse Aide (NA) Registry. The facility census was 92, and the deficient practice was identified as having the potential to affect all residents. The facility policy titled, Screening-Applicant, Employee, Volunteer and Vendor (Missouri), revised 06/12/25, stated Human Resources would conduct pre-employment screens, maintain results in the applicant file, and not allow an applicant to begin work until the criminal background check was completed unless otherwise approved. Record review showed Employee B was hired on 10/16/24 but the CBC, EDL, and Nurse Registry were not checked until 10/21/24; Employee C was hired on 01/31/25 and the CBC, EDL, and Nurse Registry were not checked; Employee D was hired on 09/02/24 and the NA registry was not checked; Employee E was hired on 12/03/24 and the CBC, EDL, and Nurse Registry were not checked until 03/06/25; Employee F was hired on 10/10/24 and the CBC was not checked until 08/06/25; and Employee G was hired on 12/03/24 and the CBC, EDL, and NA registry were not checked until 03/26/25. The Administrator stated Employee C, Employee E, and Employee F did not have updated CBC, EDL, or NA registry checks since their hire dates, and said NA registry checks were done only on CNAs and CMTs through TMU. The Administrator and DON stated they would expect all employees to have CBC/EDL and NA registry checks completed before hire.
Inconsistent and Missing Code Status Documentation
Penalty
Summary
The facility failed to ensure that residents’ code statuses were listed in the chart, care planned, and kept up to date with the most accurate information for four sampled residents. Review of the facility policy showed that residents’ advance directives and related physician orders were to be documented in the medical record, verified on readmission if previously provided, and communicated to staff. However, the records for Resident #1 showed a conflict between a Physician’s Order Sheet listing Full Code and a care plan with DNR interventions, along with a full code status sheet signed on a separate date. Resident #16 had no code status listed in the electronic charting system, no code status on the POS, and no code status on the care plan. Resident #65 also had no code status listed in the electronic charting system or on the POS, while the care plan listed Full Code. Resident #101’s record showed a POS order for Full Code, but the care plan contained DNR interventions and there was no signed documentation for code status. During interviews, an LPN and a CMT stated that code statuses should be available in the electronic medical record and in a book at the nurse’s station, though neither was sure where the book was located. The Administrator and DON stated they would expect residents to have a code status order and for the code status to be documented consistently throughout the chart.
Incomplete discharge documentation for a resident with behavioral concerns
Penalty
Summary
The facility failed to follow discharge procedures for one resident by not completing a discharge recapitulation and by not documenting the physician’s reason for discharge. The deficiency was identified during review of a closed record for Resident #96, whose diagnoses included dementia, Parkinson’s disease, Alzheimer’s disease, disorientation, and bipolar disorder. The facility’s policy required a physician to document the reason for transfer or discharge when a resident is moved because needs cannot be met or safety is endangered, and required an interdisciplinary discharge summary to be completed when a resident is discharged or transferred. Resident #96’s record contained an undated, unsigned, and incomplete discharge recapitulation stating the reason for discharge was inappropriate behaviors and elopement risk and that the resident was discharged to another facility. The progress notes reviewed showed medication was given on 07/21/25, but there were no discharge notes. The discharge MDS dated 07/22/25 indicated discharge to hospital with return anticipated. During interview, the Administrator stated the resident had been exit seeking and had said something to another resident that scared them, and that the decision to move the resident to another facility was made with the resident’s family member, but there was no documentation of this. The Administrator and DON stated they would expect a recapitulation of stay and a progress note to be completed at the time of discharge.
Missing transfer notices, bed-hold documentation, and discharge summary
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers to the hospital for four residents. Resident #1 was admitted, transferred to the hospital, and later returned to the facility, but there was no documentation that written notification was provided at the time of transfer. During interview, the DON stated that a transfer and bed hold had not been sent because the resident went out as an emergency. Resident #6 was admitted and transferred to the hospital, and had not yet returned at the time of review; there was no documentation of written notification to the resident or representative, and the DON stated there was not a bed hold/transfer sheet completed. Resident #16 and Resident #65 were also admitted, transferred to the hospital, and returned to the facility, with no documentation that written notification was provided to the resident and/or representative at the time of transfer. The facility also failed to complete a discharge summary with a recapitulation of stay for Resident #98. The resident was admitted and later discharged home after therapy goals had been met, but the record did not include a recapitulation of the resident's stay, including diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. During interview, the DON stated she was not sure who was responsible for bed holds, transfers, and discharges since the new owners took over, and the Administrator and DON stated they would expect written transfer and bed hold notification when a resident is discharged to the hospital and a recapitulation of stay with a progress note and reason for discharge when a resident is discharged.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to document accurate MDS assessments for five sampled residents. For Resident #2, the admission MDS dated 06/09/25 marked Section E as having a tracheostomy while the resident’s POS had no tracheostomy order, the resident was observed seated without a tracheostomy, and the DON stated the facility did not have anyone with a tracheostomy. For Resident #26, the admission MDS marked Section O as no for oxygen even though the resident had a CPAP in the room, the POS had no CPAP order or care instructions, and the resident said the CPAP was used every night. For Resident #39, the annual MDS marked no indwelling device and always urinary continent, but the resident was observed with a urinary catheter attached to a leg bag while in bed and the POS had no catheter order. For Resident #93, the annual MDS marked no for oxygen even though the resident was observed on oxygen at 2 liters per minute via nasal cannula, and the POS had no oxygen order. For Resident #96, the discharge documentation was incomplete and inconsistent, with an unsigned, undated discharge recapitulation stating discharge was due to inappropriate behaviors and elopement risk and that the resident was discharged to another facility, while the discharge MDS stated discharge to hospital with return anticipated. The Administrator stated the resident had been exit seeking and moved to another facility, but there was no documentation of this. The Administrator, DON, and MDS Coordinator stated they expected MDSs to be completed accurately per the RAI manual.
Care Plans Did Not Reflect Residents’ Actual Treatments and Needs
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four sampled residents. The report states that the facility’s policy required person-centered care plans with measurable objectives, time-frames, and resident-specific interventions, but the care plans and physician orders for these residents did not reflect their actual needs or treatments. The deficiencies were identified through observation, interview, and record review. Resident #26 had diagnoses including schizophrenia, morbid obesity, obstructive sleep apnea, and asthma. The physician order sheet had no orders for CPAP use, cleaning, or settings, and the care plan addressed altered respiratory status and breathing difficulty but did not address CPAP. The resident stated he/she used CPAP every night and was unsure whether it was cleaned. Resident #39 had diagnoses including urinary system disorder, low back pain, hematuria, dysuria, and acute kidney failure. The physician order sheet had no orders for a urinary catheter or catheter care, and the care plan did not address an indwelling catheter. Although the annual MDS indicated no indwelling device and marked urinary continence as always, observation showed a urinary catheter attached to a leg bag. The resident said the catheter had been present for a long time, caused pain, and that staff had not cleaned it; an LPN said the resident would not let staff touch him/her and the DON said there should have been catheter care orders. Resident #93 had diagnoses of dyspnea, COPD, and heart disease, but the physician order sheet and care plan did not address oxygen even though observation showed oxygen at two liters per minute via nasal cannula. Resident #101 had diagnoses of psychosis, schizophrenia, and COPD, but the physician order sheet showed no orders for side rails and the care plan did not address them, while observation showed a half side rail in use with a six-inch gap between the rail and mattress and the rail wobbling when the resident grabbed it.
Lack of Orders and Care Planning for Urinary Catheter
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a urinary indwelling catheter by not having physician orders for the catheter or catheter care. Resident #39 was admitted with diagnoses including a urinary system disorder, low back pain, hematuria, dysuria, and acute kidney failure. The resident's POS dated 08/06/25 had no orders for an indwelling urinary catheter or catheter care, and the annual MDS dated 05/03/25 indicated no indwelling device and urinary continence marked as always. The care plan, last revised 08/06/25, addressed bladder incontinence, retention of urine, hematuria, and urinary system disorder, but did not address an indwelling urinary catheter. Observations showed the resident in bed with a urinary catheter attached to a leg bag on 08/04/25 and again on 08/06/25. During interview, the resident stated the catheter would hurt at times, that staff said they could not remove it without an order, and that staff did not clean it; the resident said he or she usually handled the catheter and supplies personally. An LPN stated the resident would not let him or her touch the resident and that the DON mostly took care of the catheter, while the DON stated the resident had frequent urinary tract pain, would say he or she was not urinating and call 911, and tended to get frequent UTIs. The DON also confirmed there were no orders for the catheter or catheter care, and the Administrator and DON stated they would expect residents with a urinary catheter to have a physician's order and to be care planned appropriately.
Missing CPAP and Oxygen Orders
Penalty
Summary
The facility failed to obtain orders for CPAP settings and tubing changes for one resident with a CPAP. Resident #26 was admitted on 07/08/25 with diagnoses including paranoid schizophrenia, disorganized schizophrenia, schizoaffective disorder, manic episodes with psychotic symptoms, congestive heart failure, and borderline intellectual functioning. On 08/05/25, the resident was observed with a CPAP in the room and stated staff filled it up and it was used every night, but the Physician's Order Sheet dated 07/08/25 had no order for CPAP, no order to clean the CPAP or tubing, no order for changing CPAP parts, and no order for CPAP settings. The comprehensive care plan revised 07/15/25 did not address CPAP use, settings, cleaning, changing parts, or tubing. The facility also failed to obtain a physician's order prior to oxygen use and orders for nasal cannula and humidifier changes for one resident with oxygen. Resident #93 was admitted on 07/08/24 with diagnoses including pneumonia, atrial fibrillation, heart failure, COPD, dyspnea, and other cardiovascular and neurologic conditions. Observations showed the resident wearing oxygen at 2 liters per minute via nasal cannula with tubing dated 07/18/25 and later tubing dated 08/01/25. The Physician's Order Sheet dated 04/28/25 had no order for oxygen settings and no order to check the oxygen bubbler, although it did include an order to change oxygen tubing every Friday and as needed for leakage, contamination, and infection. The comprehensive care plan revised 07/15/25 did not address oxygen use. During interview, the resident said staff changed the oxygen tubing monthly and that the tubing dated 08/01/25 had been changed the day before. The Administrator and DON stated they would expect residents with CPAP to have orders including settings and cleaning instructions, and that oxygen tubing should be changed according to orders and dated appropriately.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment and failed to review the risks and benefits of bed rail use before installation or use. The facility also failed to obtain informed consent from the resident and/or resident representative for two residents in the sample and two residents outside the sample. The facility’s policy required assessment of alternatives attempted, assessment of entrapment risk, informed consent, and correct installation and maintenance of bed rails, including compatibility of the bed frame, mattress, and rail. Resident #46 had diagnoses including abnormal posture, muscle weakness, lack of coordination, gait and mobility abnormalities, and unspecified osteoarthritis. The record contained no signed consent form explaining the risks and benefits of bed rail use and no completed entrapment assessment. The care plan did not address bed rail use. The resident was observed in bed with a half bed rail up on the left upper side of the bed on two occasions. Resident #74 had diagnoses of encephalopathy and tremors. The record contained no signed consent form and no completed entrapment assessment, and bed rail use was not care planned. The resident was observed with a half rail up on the left side of the bed, and during interview said he/she did not use the bed rail and was not sure why it was there. Resident #80 had diagnoses including failure to thrive, dementia, cognitive communication deficit, and muscle weakness; a physician order dated 03/31/25 for a half bed rail per resident request; no signed consent form; and no completed entrapment assessment. Resident #101 had diagnoses of psychosis, schizophrenia, and COPD; a side rail assessment completed on 2/24/25 indicated no side rails, but the care plan later showed a half side rail to assist with turning and repositioning, with no signed consent form in the record. During observation, the resident used the rail to get up and out of bed, and staff acknowledged the gap between the rail and mattress and that an assessment to assure proper fit had not been done.
Medication Error Rate Exceeded During Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during insulin administration. Surveyors found 27 opportunities with three errors, resulting in an error rate of 11.11%. The deficiency affected one resident in the sample and one resident outside the sample, with the potential to affect all residents in the facility. The facility’s policy required insulin to be administered according to physician’s orders and required insulin pens to be primed with two units before use. During observation, CMT M obtained finger stick blood sugars for two residents and administered Humalog insulin from a pen-type device, but did not prime the pen with two units before giving the ordered doses. One resident received two insulin administrations during the observation period, and neither dose was preceded by priming the pen. In interview, CMT M stated he/she did not know insulin pens had to be primed before administration. The Administrator and DON later stated they would expect insulin pens to be primed prior to insulin administration.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
The facility failed to provide palatable, attractive food at safe and appetizing temperatures. Based on observation, interview, and record review, four sampled residents and four additional residents outside the sample were affected, with the potential to affect all residents in the facility. The facility’s Dietary Food Policy required meals to be prepared in adequate amounts, foods to be served at proper temperatures, hot foods to be above 135°F, cold foods to be less than 41°F, salads to be refrigerated until service, and sandwiches to be served at appropriate temperatures. During meal observations, the test trays showed multiple items served outside the facility’s stated temperature standards and with poor appearance/texture. At lunch, items included watermelon at 63.1°F, lunchmeat in a hotdog bun at 61.8°F, penne noodles with broccoli at 78°F, and slaw with mayonnaise at 62.9°F. At dinner, a cheese quesadilla was 107°F, rice with tomatoes and corn was 120°F, and chocolate cake was described as dry. At another lunch, meatballs with sauce were 97.3°F, mashed potatoes were 113°F, green beans were 91.2°F, and canned peaches were 61.3°F. Residents reported the food was cold, not good, bland, tough, questionable, and served in small portions, and Resident Council members said dietary staff were not using real eggs, served cold French fries, and melted ice cream. The Administrator and DON stated they would expect food to be palatable and within the appropriate temperature range.
Failure to Use Infection Control Practices During Wound, Peri, and Foley Care
Penalty
Summary
The facility failed to maintain infection control practices during wound care and failed to implement enhanced barrier precautions (EBP) during perineal care and Foley catheter care for one resident. The resident had a Foley catheter and a buttock wound that required dressing care. The facility policy stated that EBP, including gown and gloves, must be used for high-contact resident care activities for residents with wounds and/or indwelling medical devices, and that any wound care requires EBP. During observation of peri care and Foley catheter care, a CNA entered the resident’s room without putting on gloves and a gown. The CNA performed hand hygiene, then put on gloves and cleaned the resident’s peri area and Foley catheter from the insertion point down the tubing. The CNA did not change gloves or perform hand hygiene while rolling the resident, cleaning the right buttock, left buttock, and rectal area, and obtaining clean wipes from the container. The CNA later changed gloves and performed hand hygiene before placing a clean incontinent pad and repositioning the resident. During observation of peri care and wound care, an LPN entered the resident’s room without donning a gown for EBP and did not clean and sanitize the bedside table before placing supplies on it. The LPN removed the soiled dressing, changed gloves without performing hand hygiene, and continued wound and peri care while repeatedly changing gloves without hand hygiene between tasks. The LPN cleaned fecal material from the resident’s buttocks, applied calmoseptine to the buttock wound, and applied a border foam dressing. During interview, the LPN stated he/she had never heard of EBP and said supplies should be kept outside the room and hands should be washed or sanitized between glove changes.
Failure to Inspect and Assess Bed Rails and Bed Components
Penalty
Summary
Facility staff failed to conduct regular inspections of bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for Residents #80 and #101, and for Residents #46 and #74 outside the sample. The facility census was 92. The facility’s Proper Use of Bed Rails policy required correct installation, use, maintenance, compatibility of the bed rail, mattress, and bed frame, regular checking of bed rails, and routine preventative maintenance. The Bed Maintenance and Inspection policy required the Maintenance Director or designee to keep records of bed inspections and maintenance and to place bed frames, mattresses, and bed rails on a regular scheduled inspection and maintenance cycle according to manufacturer recommendations. Resident #46 had no maintenance inspection in the record and was observed lying in bed with a half rail up on the left side. Resident #74 also had no maintenance inspection in the record and was observed sitting in a chair in the room watching TV with a roommate, with a half rail up on the left side of the bed. Resident #80 had no maintenance inspection in the record and was observed lying in bed with a raised half rail on the right side of the bed; later the resident was not in the room and a call light was draped around the raised half rail on the right side of the bed. Resident #101 had no maintenance inspection in the record and was observed lying in bed with a half rail on the left side of the bed. During the observation, the resident said the rail was used to get up and out of bed, and when the resident grabbed it, the rail wobbled. The space between the half rail and mattress was approximately six inches, and the metal bed frame was larger than the mattress. The Administrator acknowledged the gap and said she would have expected an assessment to assure the handrail was a proper fit, but it had not been done. The Maintenance Director said he/she made sure the handrails were maintained but had not done an actual assessment. The Administrator and DON said they would expect bed rails to have a physician’s order, an accurate and current assessment, and for bed rails to be assessed and maintained so the mattress, bed, and bed rail(s) were not posing a hazard.
Missing Annual Dementia Care Training for CNAs
Penalty
Summary
The facility failed to provide the required annual competency training on dementia care for three of three sampled CNAs. Review of the in-service records for CNA H, CNA I, and CNA J showed each had completed 16 hours of annual in-services, but none had documented annual dementia care training. The facility also did not provide a policy regarding the required annual nurse aide training requirements. During interview, the DON stated he/she conducts nursing in-services, that staff are expected to complete a large packet each January and monthly trainings through the facility's online training program, but he/she was unsure whether the trainings applied to all employees or only nursing staff, how the facility tracked completion, and how many trainings were completed. The DON said he/she was unaware of the mandatory trainings required. The Administrator and DON later stated they would expect dementia care training to be part of orientation and annual in-services.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to provide residents and visitors easy access to the nursing home's survey results and any plan of correction. Review of the Resident Rights policy showed that residents have the right to examine the most recent survey results and plan of correction, that the results must be available in a place readily accessible to residents, and that the facility must post a notice of their availability. Observations in the reception/entry area on 08/04/25 and 08/05/25 found no survey binder. During interview, the Receptionist stated the survey results were kept in a folder on the desk and resident copies were in folders in the activities room, meaning they were not accessible without asking and no posting of their availability was observed. The Administrator and DON stated they would expect survey results to be available for residents and/or family members and readily accessible.
Nurse Staffing Data Not Posted Daily
Penalty
Summary
The facility failed to post the nurse staffing data in a clear and readable format, in a prominent place readily available to residents and visitors, on a daily basis at the beginning of each shift. The facility census was 92. Review of the facility’s Nurse Staffing Posting Information Policy, revised 06/26/24, showed that the Nurse Staffing Sheet was to be posted daily and include the facility name, current date, current census, and total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and that it was to be posted at the beginning of each shift in a prominent, readily accessible location. Observations on 08/06/25 and 08/07/25 showed the nurse staffing data was not posted. During interview, the DON said staffing data was typically posted daily and that the forms were filled out and somewhere on his/her desk. Later, the Administrator and DON said they would expect staffing to be posted daily.
Failure to Administer Medications as Ordered During Pharmacy Transition
Penalty
Summary
Facility staff failed to administer medications as ordered by physicians for two residents out of a sample of five, in a facility with a census of 82. The facility's own policies required medications to be administered as ordered and within a specific time frame, but multiple doses of critical medications were missed for both residents. For one resident with complex medical conditions including osteomyelitis, hypertension, heart failure, atrial fibrillation, and chronic obstructive pulmonary disease, there were numerous missed doses of IV antibiotics, antihypertensives, anticoagulants, and other essential medications. Documentation showed that these medications were not available and not administered over several days, with some missed doses specifically noted as due to medication unavailability. The resident's medical records indicated significant health events during this period, including episodes of severe hypertension, lightheadedness, and a fall. Progress notes documented that the resident experienced elevated blood pressure readings, lightheadedness, and eventually required transfer to the hospital, where diagnoses included cerebellar infarct, acute kidney injury, and osteomyelitis. There was also a lack of nursing documentation regarding some of the elevated blood pressure readings and missed medication administrations. For another resident with vascular dementia, cervical disc degeneration, chronic kidney disease, and hypertension, there were also missed doses of prescribed medications, including donepezil and gabapentin, over several days. Interviews with staff revealed that the facility had recently changed pharmacies, resulting in delays and gaps in medication availability. Staff reported that the previous pharmacy supplied medications only through the end of the month, and the new pharmacy was unable to provide medications immediately due to insurance and supply issues. The facility did not have a secondary pharmacy or adequate emergency medication supplies to cover the transition period.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, which increased the risk of cross-contamination and food-borne illness for all residents served by the kitchen. Observations revealed numerous items in the walk-in refrigerator and freezer that were not labeled or dated, and the floors were covered in dirt and debris. Additionally, the double door freezer inside the kitchen contained undated and unlabeled food items in plastic storage bags. The facility's policy required that all food be appropriately dated to ensure proper rotation by expiration dates, but this was not adhered to. Further observations in the dry food storage room showed several dented cans, opened and unsealed bags of food without dates or labels, and dry goods stored in bins containing dirt, debris, and dead insects. The stove top, oven, and lower storage counter were also found to be covered in dirt and debris. The Dietary Manager admitted to not having logs for the refrigerator, freezers, and dishwasher for the last week, and the logs for July and August were incomplete, with only a few days recorded. During food preparation, a dietary aide was observed preparing sandwiches without wearing gloves and placing bread directly on a dirty counter. The Dietary Manager and other staff acknowledged the expectation for gloves to be worn when handling food and for food to be kept off counters. The Administrator and Assistant Director of Nursing also confirmed these expectations, along with the removal of expired or dented food items and maintaining cleanliness in the food storage and preparation areas.
Privacy Violation in Shower Room
Penalty
Summary
The facility failed to protect residents' right to privacy during bathing by not ensuring that other residents did not enter the shower room during showers and by not providing a shower curtain in the 100 hall shower room. This deficiency affected two sampled residents and one resident outside the sample. Observations revealed that the shower room lacked a curtain, and there was no indication to those outside the room that it was occupied. Interviews with residents indicated discomfort and embarrassment due to the lack of privacy, with some residents reducing their shower frequency as a result. The facility did not provide a policy regarding protection of privacy during bathing. The Administrator acknowledged the removal of the shower curtain, citing safety concerns for residents requiring physical assistance who might pull on the curtain. However, this action led to privacy issues for residents who shower independently. Housekeeping staff confirmed the absence of a shower curtain for the duration of their employment, which was a month. The Administrator suggested designating another shower room with a curtain for independent residents, but this was not implemented at the time of the survey.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control techniques during medication administration for several residents. Observations revealed that a Certified Medication Technician (CMT) did not wash or sanitize their hands before or after administering medications to multiple residents. Specifically, during medication administration for one resident, the CMT did not use hand sanitizer or wash their hands before or after the process. Similar lapses were observed with other residents, where the CMT handled medication cups with bare hands and failed to perform hand hygiene after disposing of the cups. Additionally, the CMT was observed administering eye drops to a resident without changing gloves after handling the medication cart, and did not wash or sanitize hands after removing gloves. During interviews, the CMT claimed to normally practice hand hygiene, but the observed actions contradicted this statement. The facility's Administrator and Director of Nursing expressed an expectation for staff to perform hand hygiene between handling clean and dirty items and between residents during medication administration.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 862 citations issued within 25 miles in the last 12 months — including the 15 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arnold
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Manor Nursing Center | 2.6 mi | ★★★★★ | 15 | 0 |
| Delmar Gardens South | 2.7 mi | ★★★★★ | 0 | 0 |
| Maple Grove Wellness & Rehabilitation | 3.2 mi | ★★★★★ | 24 | 0 |
| Delmar Gardens Of Meramec Valley | 3.2 mi | ★★★★★ | 5 | 0 |
| Fieser Nursing Center | 3.7 mi | ★★★★★ | 22 | 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.