Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Steelville Senior Living during CMS and state inspections, most recent first.
The facility failed to designate a qualified Director of Food and Nutrition Services when it did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Manager’s file lacked documentation of food service management education, certification, or experience, and the DM stated he/she had no food service training, no college or food service courses, and no kitchen supervisory experience. The administrator said there was no policy for DM qualifications and acknowledged the current DM did not meet the requirements.
Hot foods were served below required temperatures and room trays were delivered cold. Staff observed mechanical soft, pureed, and regular menu items in steam tables and warming cabinets at temperatures as low as 110 degrees F, 123 degrees F, and 122 degrees F at service, and room trays were delivered with ravioli and vegetables at 115 degrees F, 110 degrees F, 95 degrees F, and 85 degrees F. Residents reported that meals in their rooms were often cold, while the DM and administrator acknowledged inconsistent temperature control and unclear reheating practices.
Improper Food Labeling and Storage in Dietary Areas: The kitchen had multiple opened, undated, and improperly stored food items in dry storage and the walk-in refrigerator, including bins and bags of sugar, flour, marshmallows, rice, cereal, produce, and cooked sausage. A scoop was also stored inside food containers, and several items were left open to the air. The DM said staff were responsible for dating food after receipt and opening, and the Administrator said the DM was responsible for ensuring food was labeled, dated, and rotated.
Staff failed to provide consistent ADL assistance with bathing, personal hygiene, and grooming to multiple dependent residents, despite facility policies and care plans requiring such care. Over several months, some residents received only one or two showers, with long gaps between bathing, while others reported going weeks without showers and having to perform their own bed baths. Surveyors repeatedly observed residents with strong body or urine odors, oily or disheveled hair, unchanged clothing, and unshaven facial hair, while care plans often lacked individualized grooming preferences. Staff interviews, including CNAs, a CMT, an RN, the DON, and the administrator, confirmed that residents were not receiving scheduled showers due to chronic staffing shortages, lack of dedicated shower aides, and difficulty managing residents who resisted care, particularly on a special care unit.
Missing Neuro Checks, Fall Documentation, and MAR/TAR Entries: Staff failed to complete required neuro checks for two residents after falls, failed to document a resident’s fall and post-fall assessment after the resident reported falling with left knee swelling and pain, and failed to document multiple ordered meds/treatments for several residents, including tube feeding care, wound care, and skin treatment. Interviews with RN, DON, and admin confirmed that missing MAR/TAR signatures meant the care was not documented.
Failure to Follow Standardized Menu and Recipe Serving Size: A cook served residents on regular diets fewer ravioli than directed by the menu and standardized recipe. The DM told the cook that six ravioli was one serving, even though the DM had not reviewed the recipe and did not know the size of the ravioli being served. The administrator stated the DM was responsible for ensuring kitchen staff followed the standardized menus and recipes.
Hand hygiene and glove changes were not followed during incontinence and catheter care for multiple residents. Staff used visibly soiled gloves while moving from dirty to clean tasks, handled clean items and resident belongings without washing hands between glove changes, and left rooms without hand hygiene. CNAs and NAs stated they knew gloves should be changed between dirty and clean care and hands should be washed before, during, and after care, but did not do so during the observed care events.
Staff failed to consistently document and follow physician‑ordered wound care for a resident with a Stage 3 sacral pressure ulcer, with multiple missed entries on the TAR for daily sacral treatments. Another resident, who was severely cognitively impaired and fully dependent for mobility, had orders and a care plan requiring being laid down after meals and use of heel protectors and positioning wedges for pressure relief. Observations showed this resident repeatedly sitting in a mechanical chair with bare heels pressed into the footrest and heel protectors left unused in the room, with no repositioning over an extended period. A subsequent skin assessment identified a new, facility‑acquired Stage 1 pressure injury on the resident’s heel, and interviews with CNAs and an RN confirmed they were unaware of the orders for heel protectors and positioning between meals.
Failure to Provide Bed-Hold Notices at Transfer: Facility staff did not provide written bed-hold information to the resident and/or representative when three residents were transferred to the hospital. Records for one resident, one resident with multiple hospital transfers, and one resident who later remained in the hospital on hospice lacked documentation that the required notice was issued. Interviews showed nursing staff and the SSD were expected to complete and follow up on the notices, but the omission was not known at the time.
Unsafe mechanical lift transfers occurred when staff failed to follow lift safety requirements. One resident with maximal transfer needs and a hip fracture was found on the floor after a CNA/CMT performed a one-person lift transfer, and staff reported the sling may not have been properly connected or sized. Two other dependent residents were observed being transferred with the lift base kept closed, while staff moved the lift, turned it, and held the resident or sling as the resident rocked in the air. Interviews confirmed staff knew two-person transfers and an opened base of support were required.
Failure to Implement Antibiotic Stewardship Monitoring Program. Facility staff did not implement an Antibiotic Stewardship Program with protocols and a system to monitor and track antibiotic use. The facility policy stated the purpose of the program was to monitor antibiotic use, but it did not direct staff on how to track and trend antibiotics. The IP said short staffing and floor work prevented completion of the program, the DON said nothing had been done with the program, and the administrator was unaware the IP could not complete its components.
Staff failed to follow hand hygiene protocols in the kitchen, including not washing hands between glove changes, after touching the trash can lid, and when moving between tasks during meal service. These actions were observed despite staff being aware of facility policy, and the deficiency was acknowledged by both the Dietary Manager and administrator.
The facility did not ensure RN coverage for at least eight consecutive hours daily, as required. Multiple dates in June, July, and August 2024 lacked RN presence, with the DON covering shifts when possible. The administrator cited scheduling challenges and an RN's recent surgery as contributing factors.
The facility failed to manage and store medications properly, leading to deficiencies such as expired medications in storage, loose pills in medication carts, and non-medication items in the medication refrigerator. Staff interviews revealed a lack of awareness and responsibility for these issues, despite existing policies requiring regular checks and proper storage practices.
The facility failed to maintain proper food storage and serving temperatures, with refrigerator logs showing temperatures above safe limits and no corrective actions documented. Observations confirmed high temperatures in the walk-in refrigerator and cold table items, which were served to residents. Additionally, kitchen wares were not fully submerged in sanitizer, contrary to policy, indicating inadequate sanitization practices.
Facility staff failed to follow proper infection control procedures, including hand hygiene and glove use, during resident care. An LPN did not wash hands between glove changes during catheter and wound care, while a CNA failed to change gloves during perineal care. A CMT improperly handled blood glucose monitoring equipment, risking contamination. Staff acknowledged these oversights, citing nervousness, and the DON and administrator reiterated the importance of proper procedures.
Facility staff failed to update care plans for two residents regarding catheter use and did not document a fall for another resident. Despite observations confirming catheter use, care plans lacked this information. Additionally, a resident's fall was not documented or addressed in their care plan. Interviews revealed unclear responsibilities for updating care plans.
The facility failed to provide residents with access to their trust fund accounts on weekends, affecting three residents. Interviews revealed that staff were unaware of the need for weekend access, and no formal policy was in place. Residents expressed frustration over the lack of access to their own money during weekends.
A facility's water management program was found lacking in comprehensive policies and procedures for the inspection, testing, and maintenance of water systems to prevent Legionella growth. The program did not document specific testing protocols, responsible staff, or acceptable control measure ranges. Positive Legionella test results for a resident and poorly controlled Legionella growth in water samples indicated lapses in monitoring and mitigation. Observations revealed water fixtures turned off due to Legionella presence, and interviews with staff highlighted gaps in knowledge regarding chlorine levels, testing protocols, and corrective actions.
Unqualified Dietary Manager Assigned Without Required Qualifications
Penalty
Summary
The facility failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications when it did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. Review of the facility’s policies showed there was no policy related to the qualifications for the Director of Food and Nutrition Services. The facility census was 50 with a capacity of 72, and the deficiency was identified through interview and record review. Review of the Dietary Manager’s personnel file showed a new hire start date of 01/26/26, but the file did not contain documentation of food service management education, certification, or experience. During interview, the Dietary Manager stated he/she had not been enrolled in food service training, had not taken college or food service courses, and had never served in a kitchen supervisory role. The Dietary Manager said he/she had worked as a cook or dietary aide for almost 15 years but did not have food service management or supervisory experience. The Dietary Manager also stated the facility’s dietician came monthly and there were no other clinically qualified staff employed full-time by the facility. The administrator stated the facility did not have a policy related to qualifications for the Dietary Manager, knew the qualification requirements, and did not know the current Dietary Manager did not meet them.
Hot Foods Served Below Required Temperatures
Penalty
Summary
Food and drink were not kept at safe and appetizing temperatures during service. The facility policy titled Food Code Temperatures, dated 02/26, directed staff to hold hot foods at 140 degrees F or above, but observation on 04/21/26 showed mechanical soft chicken strips in a warming cabinet at 110 degrees F and vegetables on a steam table at 125 degrees F. During interview, the cook said the mechanical soft chicken had been prepared but was not reheated or checked after processing because the meal had to get out to residents. On 04/22/26, a cook pureed pork loin and gravy, noted the pork temperature was 125 degrees F, and placed it in the warming cabinet; the cook said hot foods should be held at 135 degrees F to 140 degrees F but did not know how to reheat the pureed pork and did not follow the recipe because it was hard to find. The pureed pork remained at 125 degrees F in the warmer and was served at 123 degrees F, and mechanical soft pork in the warming cabinet measured 126 degrees F and was served at 122 degrees F. The facility also failed to ensure hot foods remained at least 120 degrees F when served to residents eating in their rooms. The policy did not include direction to staff on the minimum required temperatures of food at the time of service to residents. Residents reported receiving cold meals in their rooms, including one resident who said meals were cold 90% of the time, another who said hot foods were not hot and biscuits and gravy were not even warm, and a third who said food was always cold. Observation of room trays showed ravioli and vegetables at 115 degrees F and 110 degrees F on one tray, ravioli at 85 degrees F on another, and ravioli at 95 degrees F on a third tray when delivered to residents. The Dietary Manager said the cook was responsible to serve hot resident foods at 165 degrees F but did not know how often temperatures were checked, and the administrator said cooks and the DM were responsible to serve hot foods at 140 degrees F or above and to reheat mechanical soft and pureed foods to 140 degrees before service.
Improper Food Labeling and Storage in Dietary Areas
Penalty
Summary
Food was not stored in a manner to prevent potential contamination and outdated use. During observation, the kitchen dry storage area contained multiple food items that were opened, undated, or exposed to the air, including a half full bin of sugar, bins of flour, opened bags of cheese snacks, heart marshmallows, white marshmallows, pancake mix, brown sugar, and long grain rice. The facility’s provided policies did not include a policy related to food labeling, dating, or storage. Additional observations showed opened and undated bags of shredded lettuce and shredded carrots in the walk-in refrigerator, a plastic scoop stored in an unlabeled and undated container of brown powder on the cook’s preparation table, and a large undated container of salad with a plastic zipper bag of cooked sausage dated 4/23 and open to the air. The dry goods storage area also contained a scoop stored in an undated bin labeled as thickener, a box of wheat hot cereal dated 03/15 open to the air, a box of long grain rice dated 01/05/26 open to the air, and several other opened or undated food items including chocolate chips, cocoa powder, powdered sugar, breadcrumbs, brown sugar, flour, heart shaped marshmallows, and mini marshmallows. The Dietary Manager stated cooks and dietary aides were responsible for dating food when it arrived and after opening, that food should be stored sealed and not exposed to the air, and that scoops should not be stored in food containers. The Administrator stated the DM was responsible for ensuring kitchen staff labeled and dated all food items and that food should be rotated and used or discarded by use-by dates.
Failure to Provide Required ADL Assistance With Bathing and Hygiene
Penalty
Summary
Facility staff failed to provide required assistance with activities of daily living (ADLs), particularly bathing, hygiene, and grooming, to multiple dependent residents, despite facility policies requiring appropriate support with hygiene, bathing, dressing, and grooming in accordance with each resident’s care plan. The facility’s ADL and bathing policies required staff to provide care for residents unable to carry out ADLs independently, to document showers and refusals, and to explore causes of care resistance rather than assuming refusal. Record review showed significant gaps in shower documentation for several residents over a multi‑month period, and care plans often lacked individualized details such as facial hair preferences and behavioral approaches for residents with dementia or behavioral issues. One cognitively intact resident with lower extremity impairment and osteoporosis reported receiving only one shower since admission in January, with staff using wipes only in the diaper area and not offering bed baths or shaving assistance, despite the resident’s inability to manage facial hair. Observations over several days showed persistent upper lip and chin hair, and shower records reflected only a single shower in more than two months. Another resident with dementia, TBI, bipolar disorder, and schizophrenia, who was fully dependent for bathing and hygiene, had only one partial bed bath documented over a three‑month period. Repeated observations showed disheveled, knotted hair and long chin hair. Staff interviews indicated the resident was combative with care, required two to three staff for showers, and sometimes needed PRN medication beforehand, but there was usually only one staff member on the special care unit, making it difficult to complete showers or facial care, and behavior details were not consistently documented. Additional residents who were dependent or required maximal assistance for bathing and dressing also did not receive showers as planned or preferred. One cognitively intact resident dependent for bathing had no ADL assistance needs documented in the care plan; this resident’s room and person had a strong sour body odor, and the resident reported not getting enough showers, with weeks between some showers and never receiving the expected twice‑weekly showers. Another cognitively intact resident dependent for bathing and dressing had only two showers documented over nearly three months and was repeatedly observed with several white chin hairs, stating it had been a while since the last shower and that shaving usually occurred during showers. A resident with dementia, TBI, and physical impairments, fully dependent for bathing and hygiene, had only two showers documented over a similar period and was repeatedly observed with disheveled hair, the same clothing, and facial hair about 0.5 inches long, reporting a preference to be clean shaven but not having been shaved due to lack of showers. Further, a cognitively intact resident requiring maximal assistance for bathing and lower body dressing, and who occasionally rejected care, had a care plan specifying at least one shower per week, yet records showed a refused shower followed by a gap of several weeks before the next shower, and the resident reported being “lucky” to get one shower a week and sometimes going at least two weeks without one. Observations noted strong urine odor in the room and on the resident, and oily, clumped hair. Another cognitively intact, fully incontinent resident requiring extensive assistance for bathing and dressing had only two showers per month documented over three months and reported not having had a shower in about a month, with a recent request for a shower not fulfilled, leading the resident to perform self‑bed baths. Multiple CNAs, a CMT, an RN, the DON, and the administrator acknowledged that residents were not receiving scheduled showers, citing chronic staffing shortages, lack of dedicated shower aides, and missed showers for weeks at a time, with staff reporting residents going up to 16 days or more without showers and noticing body odors in the halls. Across these cases, care plans often omitted specific grooming preferences such as facial hair management and did not consistently address behavioral approaches for residents who resisted care. Shower sheets and documentation showed infrequent showers, missed weekly showers, and limited recording of refusals or interventions. Staff interviews consistently described inadequate staffing, absence of assigned shower staff, and difficulty providing showers and hygiene care, particularly on the special care unit and on shifts with only one aide. Residents’ own reports and repeated surveyor observations of body odor, urine odor, disheveled hair, oily hair, unchanged clothing, and unshaven facial hair corroborated that ADL assistance with bathing, personal hygiene, and grooming was not being provided as required for multiple residents who were dependent on staff for these services.
Missing Neuro Checks, Fall Documentation, and MAR/TAR Entries
Penalty
Summary
The facility failed to ensure staff followed acceptable standards of practice when neurological checks were not completed for two residents after falls. One resident had an unwitnessed fall on 04/06/26, and the medical record did not contain 9 of 22 required neurological checks. Another resident had an unwitnessed fall without injury on 09/18/25 and a witnessed fall with head involvement on 10/30/25; the record did not contain documentation of neurological checks for the first fall and did not contain 18 of 22 neurological checks for the second fall. Facility policy stated neurological checks were to be performed after an unwitnessed fall or a fall with suspected head injury and documented in the medical record. The facility also failed to document a resident’s fall and post-fall evaluation. One resident reported falling in the bathroom and landing on the left knee, with staff assisting the resident up after the fall. Observation showed swelling and purplish discoloration above the left kneecap, and the resident continued to report pain and swelling over the next two days. Staff interviews indicated a CMT, LPN, and NA were aware of the event and the resident’s knee pain, but the EMR contained no documentation of the fall, post-fall evaluation, or follow-up. The DON and administrator stated they had not been notified of the fall and found no documentation of it in the record. The facility further failed to document administration of ordered medications and treatments for four residents. One resident with a feeding tube had missing documentation for daily weights, split drain gauze care, tube flushes, and tube feedings on multiple days in March and April 2026. Another resident with pressure-injury risk had missing documentation for calmoseptine treatment on several dates in April 2026. A third resident with an open area under the abdominal fold had missing documentation for wound care on multiple dates in March and April 2026. Facility staff, including an RN, DON, and administrator, stated that missing signatures on MARs and TARs meant the care was not documented and likely not completed.
Failure to Follow Standardized Menu and Recipe Serving Size
Penalty
Summary
The facility failed to serve food in accordance with the nutritionally calculated recipes and menus for residents on regular diets. The facility’s menu for 04/21/26 directed staff to serve 10 ravioli with garlic cream sauce at lunch, and the standardized recipe for regular textured ravioli with garlic cream sauce also directed staff to serve 10 ravioli. During observation at 12:30 P.M., a cook served residents on regular diets six ravioli instead of the amount directed by the menu and recipe. In interview, the cook said the Dietary Manager told him/her that six ravioli was one serving and stated he/she did not check the standardized recipe to verify the serving size. The Dietary Manager later stated he/she believed six ravioli was one serving based on prior hospital experience, did not know the size of the ravioli being served, and did not review the standardized recipe before instructing the cook on serving size. The Dietary Manager also stated that all staff who prepare and serve meals are responsible for following the standardized recipes and serving sizes, and the administrator stated the Dietary Manager is responsible for ensuring kitchen staff follow the standardized menus and recipes.
Hand Hygiene and Glove Changes Not Followed During Resident Care
Penalty
Summary
Staff failed to use appropriate hand hygiene and glove changes during incontinence care for multiple residents. The facility policy titled Handwashing/Hand Hygiene directed staff to perform hand hygiene before and after direct resident contact, before donning gloves, after removing gloves, and when moving from a contaminated body site to a clean body site during resident care. The survey found that staff did not follow these directions during observed care events involving Residents #9, #2, #27, and #30. During care for Resident #9, a nurse aide wore the same gloves while wiping stool from the resident’s buttocks, handling a clean brief, rolling the resident, and providing frontal perineal care. The aide wiped stool from the gloves with a wipe, continued care with visibly soiled gloves, removed gloves without washing hands, applied new gloves, and continued care with stool still visible on the wipes. The aide also touched the clean wipe package, the resident’s blankets, and pillow, and left the room without performing hand hygiene. During care for Resident #2, a CNA wore visibly soiled gloves while wiping stool, continued from dirty to clean care without changing gloves or washing hands, placed a clean brief, and pushed unused wipes back into the clean package. After removing gloves, the CNA touched the resident’s blanket and bed remote without hand hygiene, then left the room, went to the dirty utility room, and returned to the hall to help another resident without performing hand hygiene. Similar observations were made for Resident #27, where a nurse aide used the same soiled gloves to wipe bowel, place a clean brief, fasten the brief, pull up clothing, and apply a gait belt, then changed gloves without hand hygiene and touched the resident’s mechanical chair handles before leaving without hand hygiene. For Resident #30, two CNAs performed transfer and catheter care while repeatedly removing gloves and putting on clean gloves without hand hygiene between tasks, including catheter care, perineal care, applying cream, and emptying the catheter bag. Staff interviews confirmed they knew gloves should be changed between dirty and clean care and hands should be washed before and after care, but stated they did not do so because it slipped their mind or they were in the middle of care.
Failure to Follow Wound Care Orders and Heel Offloading Interventions Resulting in Pressure Injury
Penalty
Summary
Facility staff failed to ensure physician‑ordered wound care was consistently documented and provided for one resident with an existing pressure ulcer and failed to implement ordered pressure‑relief interventions for another resident, resulting in a new in‑house pressure injury. For the first resident, the admission MDS documented existing pressure injury risk, including a scar over a bony prominence, at least one unhealed pressure injury, and a Stage 1 pressure injury, with orders for nonsurgical dressings and topical treatments. The care plan identified a Stage 3 sacral pressure ulcer and directed staff to administer treatments as ordered and monitor for effectiveness. The physician’s orders specified daily sacral wound care on the day shift, including cleansing with wound cleanser, patting dry, applying skin prep to the peri‑wound, fitting calcium alginate to the wound bed, and covering with a bordered gauze dressing. Review of the Treatment Administration Records (TARs) for this resident showed multiple dates where the ordered sacral wound treatment was not documented as given. In March, there was no documentation of treatment on two specific dates, and in April, there were additional missed entries on several dates. The report does not state that the treatment was provided but simply not recorded; it only establishes that staff did not document that the ordered wound care was administered on those days, despite the resident’s identified risk and existing Stage 3 sacral ulcer. For the second resident, the Quarterly MDS documented severe cognitive impairment, bilateral lower extremity ROM issues, total dependence on staff for bed mobility and transfers, and risk for pressure injuries, with a turning/repositioning program in place. The care plan and physician orders required weekly skin assessments, that the resident be laid down after meals if agreeable, and that heel protectors and positioning wedges be used for turning and repositioning. The MAR showed nurses signed that the resident was laid down after meals with heel protectors on for some days, but one day’s after‑breakfast and after‑lunch entries were not signed. Multiple observations over several days showed the resident sitting in a mechanical chair with heels pressed firmly against a depressed footrest, without shoes and without heel protectors, which were seen in the corner of the room instead of on the resident. Continuous observation on one morning showed the resident remained in the same position without turning or repositioning by staff. A subsequent weekly skin assessment documented a new, in‑house acquired Stage 1 pressure injury on the right heel, with non‑blanchable erythema and intact surrounding tissue. Interviews with CNAs and an RN revealed they were unaware of the orders to lay the resident down between meals and to use heel protectors, and they reported that heel protectors had not been used for approximately a year, despite the existing orders and documentation on the MAR.
Failure to Provide Written Bed-Hold Notices at Hospital Transfer
Penalty
Summary
Facility staff failed to provide written bed-hold information to the resident and/or the resident's representative at the time of transfer to the hospital for three residents sampled. The facility policy titled Bed-Holds and Returns, dated October 2022, stated residents and/or representatives are to be informed in writing of the facility and state bed-hold policies at admission and again at transfer, or within 24 hours if the transfer is an emergency. The written notice is to explain the state bed-hold duration, reserve bed payment policy for Medicaid residents, the facility bed-hold policy, the per-diem rate to hold a bed when applicable, and the return policy. Review of the records for Resident #1, Resident #4, and Resident #52 showed hospital transfers and returns or anticipated return, but no documentation that a bed-hold notice was issued to the resident or responsible party upon discharge. Resident #4 had multiple hospital transfers and returns documented, and Resident #52 was transferred with return anticipated but remained in the hospital on hospice. During interviews, RN K, the SSD, the Interim DON, and the Administrator each stated that nursing staff should provide the bed-hold notice when a resident leaves for the hospital and that the SSD should follow up, but they did not know the notices had not been completed.
Unsafe Mechanical Lift Transfers
Penalty
Summary
Facility staff failed to ensure that mechanical lift transfers were performed safely for three residents who were dependent on staff for transfers. The facility’s mechanical lift manual stated that two assistants should be used for lifting and transferring procedures, that the lift legs must be in the maximum open and locked position before lifting, and that the resident should not be moved if the sling is not properly connected to the hanger bar. The report documented that staff did not follow these instructions during multiple resident transfers. One resident, who had maximal assistance needs for bed mobility and transfers, a hip fracture, and a surgical wound, was involved in a witnessed incident in which the resident was found on the floor between the legs of the mechanical lift with the head and shoulder on one of the lift legs and the legs still on the bed. The resident stated the head had been hit and complained of pain in the left shoulder, left knee, left hip, and lower back. Staff interviews indicated a CNA/CMT performed the transfer alone, despite knowing that two staff were required, and one staff member reported that a strap on the sling may not have been connected. Another staff member stated the resident had been transferred with a bariatric sling that was too big and that the resident slipped through one of the holes. Two other residents, both dependent on staff for mechanical lift transfers, were observed being transferred with the lift base fully closed rather than opened. During one transfer, staff moved a resident from a mechanical chair to bed and then back again while the resident rocked significantly in the sling, with staff walking around the bed and holding the sling or resident rather than using an opened base of support. During another transfer, staff moved a resident from a wheelchair to bed while the lift base remained closed throughout the transfer, and the DON held the resident or sling while the lift was moved and turned. Interviews with staff and leadership confirmed that staff should open the lift base before lifting and that the closed base could cause the lift to tip over, but the administrator stated he/she was not aware staff were still doing one-person mechanical lift transfers and did not know whether all staff had been trained to open the base of support.
Failure to Implement Antibiotic Stewardship Monitoring Program
Penalty
Summary
Facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility’s policy titled, Antibiotic Stewardship, revised 12/2016, stated the purpose of the program is to monitor the use of antibiotics, but it did not direct staff on how to track and trend antibiotics in the facility. During interview, the Infection Preventionist said he/she was hired in November 2025, received certification at the end of December 2025, and had not kept up with the program because of short staffing and working on the floor. The Infection Preventionist said he/she should ensure antibiotics have stop dates, track and trend antibiotics, and ensure the antibiotics are effective. The DON said he/she had not been doing anything with the antibiotic stewardship program and was not aware the Infection Preventionist was not tracking and trending antibiotics because of short staffing. The administrator said he/she was not aware the Infection Preventionist was unable to complete components of the antibiotic stewardship program and stated the importance of the program is to avoid antibiotic resistance.
Failure to Perform Hand Hygiene in Kitchen During Meal Service
Penalty
Summary
Facility staff failed to perform proper hand hygiene in the kitchen during meal service, as observed on multiple occasions. Staff were seen applying gloves, handling food, wiping counters, removing dirty gloves, touching the trash can lid with bare hands, and then donning new gloves without washing their hands in between these activities. These actions were in direct violation of the facility's policy, which requires handwashing whenever entering or re-entering the kitchen, before contact with food surfaces, after handling soiled utensils or equipment, after activities that contaminate the hands, and after glove removal. Staff interviews confirmed awareness of these requirements, yet staff admitted to not following them due to being behind, feeling stressed, or having no specific reason. The Dietary Manager and administrator both acknowledged that staff are expected to wash their hands at the required times and that the Dietary Manager is responsible for ensuring compliance. Despite this, staff were observed repeatedly failing to perform hand hygiene between glove changes, after touching the trash can lid, and when moving between tasks, which could lead to cross-contamination. The facility census at the time was 41 residents.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule and payroll details for June, July, and August 2024 revealed multiple dates where no RN was present in the building. Specifically, there was no RN coverage on several weekends and holidays, including dates in early June, July 4th and 5th, and early August. The facility census at the time was 41, indicating a significant oversight in staffing requirements. Interviews with the Director of Nursing (DON) and the administrator highlighted the facility's reliance on the DON to cover shifts when no RN was available. The DON mentioned that they would cover shifts unless on vacation, while the administrator noted that the DON was on call every other weekend and served as a backup. The administrator also mentioned that scheduling was done a month in advance, but unforeseen events like call-ins or no-shows were managed through a messaging system. Despite these measures, the administrator believed the DON covered the missed shifts, attributing the absence of RN coverage to the other RN's recent surgery.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility staff failed to properly manage and store medications, leading to several deficiencies. Observations revealed expired medications, specifically four bottles of Vitamin D with an expiration date of 5/24, were found in the medication storage cabinet. Interviews with various staff members, including Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), indicated a lack of awareness and responsibility for checking and discarding expired medications. The facility's policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not adhered to. Additionally, the facility failed to ensure medications were stored safely and effectively, as evidenced by the presence of loose pills in two medication carts. Observations noted loose pills of various colors and shapes in the [NAME] Way hall and Yadkin Lane hall medication carts. Interviews with CMTs and LPNs revealed that while it is the CMTs' responsibility to check for loose pills, there was no consistent schedule for these checks, leading to the oversight. The DON and Administrator were also unaware of the issue, despite the expectation that CMTs maintain the carts and check for loose pills regularly. Furthermore, the medication room refrigerator contained non-medication items such as lemon juice, energy drinks, cream soda, pudding, fruit dessert, and water, which is against the facility's policy. The policy states that medications requiring refrigeration should be stored separately from food to prevent cross-contamination. Interviews with staff, including CMTs, LPNs, the ADON, the DON, and the Administrator, showed a lack of awareness and adherence to this policy. The presence of food and drinks in the medication refrigerator was not known to the staff responsible for maintaining it, indicating a failure in monitoring and enforcing the facility's storage policies.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility staff failed to maintain proper storage and serving temperatures for food, which could lead to foodborne illnesses. The refrigerator temperature logs showed multiple instances where temperatures exceeded the maximum allowable limit of 41 degrees Fahrenheit, with no corrective actions documented. Observations confirmed that the walk-in refrigerator consistently displayed temperatures above the safe threshold, and staff interviews revealed a lack of awareness and communication regarding the issue. The Dietary Manager was unaware of the high temperatures, and maintenance was not informed due to the absence of a work order. Additionally, the facility staff did not ensure that food items on the cold table were kept at safe temperatures. Observations showed that the temperatures of milk and pudding were above the recommended 41 degrees Fahrenheit, and these items were served to residents. The Dietary Aide responsible for checking these temperatures was new and still learning the procedures, while the Dietary Manager acknowledged the responsibility of aides to monitor and maintain correct temperatures. The facility's sanitization practices were also inadequate, as kitchen wares were not fully submerged in the sanitizer solution as required. Observations showed that items like a food processor bowl, pot, and steam table pan were not completely immersed in the sanitizer, contrary to the facility's policy and the manufacturer's instructions. Staff interviews indicated a misunderstanding of the proper sanitization process, with the Dietary Manager unaware of the non-compliance.
Inadequate Infection Control Practices
Penalty
Summary
The facility staff failed to adhere to proper infection control procedures, as evidenced by multiple observations of inadequate hand hygiene and glove use during resident care. In one instance, an LPN did not wash or sanitize hands between glove changes while providing catheter and wound care to a resident with pressure ulcers. The LPN acknowledged the oversight, attributing it to nervousness, which could potentially lead to cross-contamination and infection. Another incident involved a CNA who did not change gloves or wash hands between performing perineal care and other tasks for a resident with moderate cognitive impairment and frequent incontinence. The CNA admitted to not following proper procedures due to nervousness. Both the Director of Nursing and the facility administrator confirmed that staff are expected to wash or sanitize hands between glove changes to prevent infection. Additionally, a CMT was observed not following proper procedures during blood glucose monitoring for two residents with diabetes. The CMT handled used test strips with soiled gloves and touched clean surfaces without removing gloves or performing hand hygiene. The CMT acknowledged the mistake, and both the DON and administrator emphasized the importance of proper glove use and hand hygiene to prevent contamination and infection.
Failure to Update Care Plans for Catheters and Falls
Penalty
Summary
The facility staff failed to document and update care plans for two residents regarding their use of catheters. Resident #19, who was assessed with moderate cognitive impairment and dependency on toileting, had an indwelling catheter that was not documented in the care plan dated 07/16/24. Similarly, Resident #22, who was cognitively intact and independent in toileting, also had a catheter that was not documented in the care plan. Observations on multiple dates confirmed the presence of the catheter, yet it was not reflected in the care plans. Additionally, the facility staff did not update the care plan for Resident #11 after a fall. The resident, who had severe cognitive impairment and used a wheelchair for mobility, was found on the floor on 07/30/24. However, the care plan dated 05/21/24 did not include documentation of this fall or any updated fall interventions. Interviews with the Care Plan Coordinator, Director of Nursing, and the administrator revealed that while fall interventions are discussed in weekly IDT meetings, the responsibility for updating care plans was not clearly defined, leading to these omissions.
Inadequate Access to Resident Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents had appropriate access to their trust fund accounts during weekends, affecting three residents out of twelve sampled. The facility did not provide a policy for resident funds, which contributed to the issue. Resident #19, assessed with moderate cognitive impairment, expressed frustration about not being able to access money on weekends, feeling that it was unfair as it was their own money. Resident #22, who was cognitively intact, mentioned the inconvenience of having to request money on Fridays to have cash for the weekend. Similarly, Resident #37, also cognitively intact, reported that if they did not access money by Friday afternoon, they would not have any for the weekend. Interviews with facility staff revealed a lack of awareness and procedures for providing residents access to their funds on weekends. An LPN was unsure of the protocol if a resident requested money on weekends, while the Business Office staff stated they were only available Monday through Friday and were unaware of the need for weekend access. The Director of Nursing confirmed that access was only available during weekdays and was unsure of the weekend protocol. The administrator mentioned that residents were encouraged to withdraw extra money on Fridays and could call him if they needed money on weekends, but this was not a formalized process.
Deficiency in Water Management Program for Legionella Control
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the water systems to prevent the growth of waterborne pathogens, specifically Legionella bacteria. This deficiency was highlighted following a positive Legionella test result for one resident on 02/20/24. The facility's water management program lacked documentation of specified testing protocols, responsible staff for testing, and acceptable ranges for control measures, despite having identified risk areas and control measures for those areas. The facility's water inspection and testing records revealed instances of poorly controlled Legionella growth in water samples, indicating a lapse in monitoring and mitigation efforts. Observations during a facility tour on 03/01/24 revealed signs posted to notify occupants not to use the water due to Legionella presence, with water fixtures turned off except for two fountains. The facility's water management team quarterly meeting minutes did not document corrective actions for identified Legionella growth in water samples, and the facility was recommended to engage a water management company to update the water management plan. Interviews with the administrator and maintenance director revealed gaps in knowledge regarding acceptable chlorine levels, testing protocols, and corrective actions following positive Legionella results.
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 73 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 Steelville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cuba Manor Inc | 7.3 mi | ★★★★★ | 15 | 0 |
| St James Living Center | 14 mi | ★★★★★ | 8 | 0 |
| Meramec Nursing | 18.7 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Sullivan | 19 mi | ★★★★★ | 11 | 0 |
| Aurora Health And Rehabilitation | 21.1 mi | ★★★★★ | 10 | 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 August 2026) and official state health department websites.