Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Stonebridge Owensville during CMS and state inspections, most recent first.
Unqualified Food and Nutrition Services Director: The facility failed to designate a qualified Director of Food and Nutrition Services when it did not employ a full-time clinically qualified nutrition professional. The DM had only recently taken over the role, had never served as a DM before, was not certified, did not have a degree in food service management or hospitality, and had not completed the required food manager course. The administrator stated the DM was promoted despite knowing he or she was not qualified because a qualified candidate could not be found.
Dishwasher Temperatures Below Required Sanitizing Levels: Staff failed to operate and monitor the mechanical dishwasher according to policy and manufacturer instructions. Logs showed missing temperature documentation and repeated wash temperatures below the required 155°F, with rinse temperatures also below the required 180°F at times. Observations found the dishwasher running with wash temperatures around 108-110°F and rinse temperatures below standard, while the DM said he/she had not reviewed the logs and was unaware of the temperature issue.
Wheelchairs and a mechanical chair used by three residents were repeatedly observed with dried food debris and splatter on the wheels, tires, armrests, seat, and foot pedals, along with cracked and torn armrest vinyl exposing foam. The residents had severe cognitive impairment and required assistance with eating and transfers. Staff said CNAs were responsible for cleaning the equipment after meals and on a weekly schedule, and that cracked armrests should be entered into TELS for maintenance, but the equipment was not being cleaned or reported as expected.
Failure to Complete Pre-Employment Background Screening: Facility staff failed to complete required CBC, EDL, FCSR, and CNA Registry checks for eight of ten new employees before they began working. Record review showed multiple staff had screenings completed after hire or had CNA Registry checks without dates, and the BOM stated staff were started early because the DON, ADON, and kitchen needed coverage. The administrator stated these checks were supposed to be completed before staff started in the building.
Staff failed to maintain infection control during wound care for a resident with a catheter, bowel incontinence, and pressure ulcers, including poor hand hygiene, glove changes, and contamination of clean items with soiled gloves and fecal matter. Staff also did not use EBP gowns and gloves during direct care for a resident with a pressure ulcer, despite EBP signage and PPE being available. In addition, five newly hired staff did not have documented completion of TB screening before working on the floor.
MDS assessments were not coded accurately for multiple residents. Two residents were incorrectly coded for anticoagulant use despite no anticoagulant orders, two residents were not accurately coded for CPAP and/or oxygen use despite orders, resident statements, and observations showing use, one resident’s falls with injury were omitted despite progress notes documenting multiple falls, and another resident’s psychotic disorder was not reflected on the MDS despite the POS listing Olanzapine and that diagnosis. The MDS Coordinator, DON, and administrator acknowledged the assessments should have matched the residents’ actual status and supporting records.
Incomplete care plans failed to reflect resident needs and preferences. Staff did not include oxygen and CPAP use, diabetes, activity preferences, or diet exceptions in residents’ care plans despite MDS findings, physician orders, dietary slips, and observations showing those needs and preferences. One resident used oxygen continuously and CPAP at bedtime, another had diabetes and insulin use, a third had documented activity interests, and a fourth received a pureed diet but was observed eating a sandwich.
Lack of Staff-Led Weekend Activities: Three residents stated they enjoyed activities but there were no weekend activities, leaving them bored, lost, or just laying in bed. The activity calendars showed only limited weekend options such as puzzles, books, TV, and church, and the activities director, CNA, LPN, DON, and administrator all confirmed there were no staff-led weekend activities.
A resident with sleep apnea and other chronic conditions had a CPAP on the nightstand, but the chart lacked a CPAP order with settings, frequency, and cleaning instructions, and the care plan did not address CPAP use. The record also lacked CPAP assessment documentation such as start time, duration, mode/settings, tolerance, and oxygen saturation. Staff interviews showed the CNA/CMT, LPN, MDS Coordinator, DON, and Administrator all recognized that CPAP use should be ordered and care planned, but the resident’s CPAP use was not identified in the record.
Missing Entrapment Assessments for Residents Using Bed Rails: Staff failed to complete entrapment assessments for five residents who had assist bars, grab bars, or quarter siderails in use. Records for residents with moderate cognitive impairment and residents with intact cognition lacked the required assessments, while observations confirmed the rails were upright on the beds. Interviews showed confusion between the MDS coordinator, maintenance director, DON, and administrator about who was responsible for measuring and documenting the entrapment checks.
Staff failed to use a gait belt while transferring a resident who required substantial assistance, instead lifting the resident under the arms and by clothing, which resulted in a femur fracture. The facility's policies lacked clear direction on gait belt use, and staff interviews revealed inconsistent understanding of safe transfer procedures.
Staff failed to follow medication administration protocols when an LPN prepared insulin for one resident, but the ADON administered it to another resident who did not have a physician's order for insulin. The error was not documented in the medical record as required, and the incident was discovered when the resident's family questioned the insulin administration. Staff interviews confirmed the improper preparation and administration process, as well as the lack of documentation.
A resident ingested another resident's medications after a CMT left a cup of medications on top of the medication cart and became distracted by an LPN's request to check blood glucose. The resident, who was cognitively intact and independent, accessed and consumed medications not prescribed to them, including Haloperidol, Atorvastatin Calcium, and Clozaril. Facility policy required medications to be kept inaccessible and resident identity to be verified, but these procedures were not followed.
An LPN misappropriated a resident's Oxycodone and Lorazepam by removing medication cards from a locked narcotic box, failing to account for the medications, and discarding packaging, as confirmed by video footage and subsequent investigation. The resident, who was cognitively intact and receiving opioid and antianxiety medications for chronic pain, was discharged with fewer medications than documented, leading to the discovery of the deficiency.
Facility staff failed to maintain proper infection control practices during wound and incontinence care, and dietary staff did not adhere to hand hygiene protocols. An LPN placed wound care supplies on unclean surfaces, and both an LPN and a CNA did not change gloves or wash hands between tasks. Dietary staff washed hands inadequately, despite training. The DON and administrator confirmed the importance of proper hand hygiene and clean barriers.
The facility failed to complete baseline care plans within 48 hours for five residents, as required by policy. Interviews with staff, including the DON, an LPN, and the administrator, revealed confusion and lack of accountability regarding the completion of these plans. The admitting nurse was identified as responsible, but the plans were not completed, and nursing leadership was unaware of the issue.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical needs such as oxygen therapy, contractures, PTSD, urinary catheter care, and pressure ulcer prevention. Observations and staff interviews revealed a lack of documentation and awareness, impacting the quality of care provided.
Facility staff failed to document medication administration for five residents, as required by policy. The MARs showed missing documentation for antibiotics, pain relief medications, and nutritional supplements. Interviews with a CMT, an LPN, and the DON confirmed that missing signatures indicate medications were either not given or not documented, potentially leading to incorrect dosages. Affected residents had conditions like osteomyelitis, arthritis, and cognitive impairment.
Facility staff failed to remove expired medications from medication carts and storage rooms. Observations revealed expired acetaminophen, nitroglycerin, and vaccines, among others. Interviews indicated inconsistent procedures for checking and removing expired medications, with staff unaware of the expired items.
A resident with a left hand contracture did not receive appropriate treatment to prevent further ROM decline. Despite hospital discharge notes recommending occupational therapy, the resident's care plan lacked documentation of the contracture and necessary interventions. Observations showed the resident's hand remained contracted without intervention, and staff interviews revealed a lack of awareness and action. The DON acknowledged the oversight, noting the contracture should have been care planned and communicated.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to designate a person to serve as the Director of Food and Nutrition Services with the required qualifications when it did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 72.1, and the deficiency was identified through interview and record review. The facility policy titled Food Services Manager, updated 09/28/22, stated the Food Services Manager may serve as the Director of Food and Nutrition Services if he or she met specified qualifications, including certification or education and experience requirements, and completion of a food safety and management course by no later than October 1, 2023. Record review showed the dietary manager enrolled in an online Food Protection Manager course on 02/02/26 and started it on 02/20/26, but had not completed it as of 03/24/26. During interview, the dietary manager stated he or she had worked as a cook in the facility for a little over two years, had taken over the DM position about a month earlier, had never been a DM before, was not certified, and did not have a degree in food service management or hospitality. The dietary manager also stated the facility's registered dietitian worked part-time and there were no other clinically qualified nutrition staff working full-time. The administrator stated he or she knew the DM was not qualified for the position but promoted him or her because a qualified DM could not be found, and also stated the facility did not have any clinically qualified nutrition staff employed full-time.
Dishwasher Temperatures Below Required Sanitizing Levels
Penalty
Summary
The facility failed to ensure the mechanical dishwasher operated according to the manufacturer's instructions and the facility's Dishwashing Machine Use policy to prevent cross-contamination of kitchen wares. The policy required staff to check and record wash and rinse temperatures with each cycle, monitor temperatures frequently during operation, report inadequate temperatures immediately, and stop using the dishwasher if hot water temperatures did not meet requirements. The manufacturer's specifications posted on the dishwasher required a minimum wash temperature of 155 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit. Record review showed multiple gaps in temperature documentation and repeated temperatures below the required levels. The Dish Machine - High Temperature Sanitizing Log for February 2026 showed no documented temperatures for several date ranges, and when temperatures were recorded they were below required levels. The log for March 2026 showed staff recorded wash temperatures below 155 degrees Fahrenheit each day reviewed, and the rinse temperature was last documented at or above 180 degrees Fahrenheit only on limited occasions. Observations on 03/23/26 and 03/24/26 showed the dishwasher in use with wash temperatures of 110 and 108 degrees Fahrenheit and rinse temperatures of 166 and 176 degrees Fahrenheit. During interview, the dietary manager stated he/she was not very familiar with the dishwasher, had not reviewed the temperature logs, and did not know there was an issue with the dishwasher temperatures. The maintenance director stated the dishwasher temperature issues were related to a broken water softener and later a booster heater replacement, but the dishwasher still did not reach the correct operating temperatures.
Wheelchairs and Mechanical Chair Not Properly Cleaned or Maintained
Penalty
Summary
Facility staff failed to properly clean and maintain the wheelchairs and mechanical chair used by three residents. The facility policy required wheelchairs to be free of visible dirt and to be cleaned on a weekly schedule, and the maintenance policy directed staff to enter work orders in TELS when repairs were needed. However, observations showed repeated dried food debris and splatter on wheelchair frames, wheels, tires, foot pedals, armrests, and seats, along with cracked and torn vinyl on armrests with exposed foam. Resident #41 had severe cognitive impairment, required maximal assistance with eating, was dependent for transfers, and used a wheelchair. Observations showed both armrests cracked and missing vinyl with exposed yellow foam, along with dried food debris on the wheelchair frame and foot pedals across multiple observations. Resident #45 had severe cognitive impairment, required moderate assistance with eating, was dependent for transfers, and used a wheelchair. Observations showed dried food debris on the wheels and tires and a cracked, damaged, and peeled left armrest vinyl on repeated observations. Resident #37 had severe cognitive impairment, required supervision or touching assistance with eating, was dependent for all transfers, and used a mechanical chair. Observations showed dried food debris and splatter on the chair’s armrest, wheels, and seat on multiple occasions. Staff interviews indicated CNAs were responsible for cleaning wheelchairs after meals and on a weekly schedule, but the wheelchairs were not getting cleaned. Staff also stated cracked armrests should be entered into TELS for maintenance, yet the cracked and torn armrests were not reported through that process.
Failure to Complete Pre-Employment Background Screening
Penalty
Summary
Facility staff failed to complete required pre-employment screening for eight of ten new employees before they began working in the facility. The employees identified in the record review were RN AA, Laundry Aide Z, Laundry Aide X, Dietary Aide Y, CNA S, [NAME] V, NA T, and LPN U. The facility policy titled "Background Screening Investigations" stated that background checks, reference checks, and criminal conviction checks are to be initiated within two days of an offer of employment and completed prior to employment, and that applicants with convictions involving abuse, neglect, mistreatment, or misappropriation of property are not eligible for employment. Record review showed that several employees had screening checks completed after their hire dates, and some records lacked dates for CNA Registry checks. RN AA had a hire date of 06/02/25, with FCSR and EDL checks dated after hire and a CNA Registry check without a date. Laundry Aide Z, Laundry Aide X, Dietary Aide Y, CNA S, [NAME] V, NA T, and LPN U also had background-related checks completed after hire and/or CNA Registry checks without dates. During interview, the BOM stated the screenings were not completed before staff started because the DON and ADON needed staff for overnight coverage and the kitchen needed help. The BOM stated employees spent their first day in the office completing paperwork and then worked on the floor during days two through five while competency checks were done. The administrator stated CBC, EDL, FCSR, and CNA Registry checks were supposed to be completed before staff started in the building and that the BOM was responsible for ensuring this occurred.
Infection Control Failures During Wound Care, EBP Use, and TB Screening
Penalty
Summary
Facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for a resident who had an indwelling urinary catheter, was always incontinent of bowel, and had one pressure ulcer. During wound care, an LPN and the ADON entered the resident’s room, applied gowns and gloves, and then handled multiple contaminated and clean items without changing gloves or washing hands between tasks. The LPN touched the resident’s bedside table with dried food debris, handled the bed remote, and continued care with the same soiled gloves. The ADON removed the resident’s sock and exposed a heel bandage saturated with blood, and later touched clean gauze with soiled gloves while the resident’s face wound was bleeding. The LPN also removed a soiled brief with bowel movement and the coccyx wound dressing, wiped bowel into the open wound several times, and picked up the resident’s clean brief with visibly soiled gloves before placing it back on the resident. The resident’s wound care also involved cross-contamination during treatment of the face and coccyx wounds. The LPN sprayed wound cleanser on the face wound and walked away to perform hand hygiene while the ADON continued to wear the same soiled gloves and placed clean gauze on the wound. The LPN later removed dirty gauze from the face wound and continued treatment, and the ADON and LPN both acknowledged during interview that gloves should have been changed and hands washed after contact with dirty surfaces, dirty items, and fecal contamination. The ADON stated the LPN introduced bacteria to the wound when bowel was wiped into the open coccyx wound, and the DON stated staff should not touch clean items with soiled gloves or wipe bowel over an open wound. Facility staff also failed to use Enhanced Barrier Precautions for a resident with a pressure ulcer. The resident had an EBP sign posted at the room entrance and PPE available inside the room, but staff did not wear gowns while assisting with a shower or while providing incontinence care. CNA staff stated they did not use gowns because it slipped their mind or they did not pay attention to the precautions. The IP, LPN, and DON all stated that gowns and gloves should be used for direct care such as showers and incontinence care for residents on EBP, and that the resident’s wounds and care needs met the criteria for EBP. In addition, the facility failed to screen five newly hired staff for TB in accordance with its policy requiring TB screening prior to beginning employment. Personnel records showed each of the five employees had only the first step of the two-step TB screening documented, with no evidence in the report that the second step was completed before they began working. The BOM, IP, and DON described the orientation process and stated that new staff were on the floor after their first day in the business office, and the DON stated corporate told him/her staff could work the floor before their first step TB was read.
Incomplete and inaccurate MDS coding for medications, treatments, falls, and diagnosis
Penalty
Summary
Facility staff failed to document complete and accurate MDS assessments for multiple residents when the assessments did not match the residents’ actual status or the supporting medical record. The facility policy required assessments to be completed and submitted within required timeframes, and the CMS RAI manual states that accurate assessments must be based on information from multiple sources, including the resident, direct care staff, and the medical record, and validated by the IDT. In this case, the MDS Coordinator, DON, and administrator all acknowledged that the MDS assessments should reflect the residents’ actual medications, treatments, diagnoses, and fall history. For two residents, the MDS coded anticoagulant use even though the Physician Order Sheets did not show an anticoagulant order. The MDS Coordinator stated he/she used physician orders and the MAR for coding medications and believed the entries were errors. The DON and administrator stated they expected medications to be coded correctly on the MDS and were not aware the residents were coded for anticoagulants when they were not currently taking them. For two other residents, the MDS did not accurately reflect oxygen and/or CPAP use. One resident’s admission MDS indicated no CPAP use, yet the resident stated he/she had used CPAP for many years and observations showed the CPAP on the nightstand on multiple occasions. Another resident’s quarterly MDS indicated no CPAP or oxygen use, but the POS included orders for CPAP with oxygen at bedtime and oxygen as needed, and observations showed the resident using oxygen and having a CPAP machine present. The resident also stated he/she used oxygen continuously in the room and wheelchair and used CPAP at bedtime. The facility also failed to accurately code falls with injury for one resident and a psychiatric diagnosis for another resident. One resident’s quarterly MDS indicated no falls since the prior assessment, but progress notes documented three falls with injury after the prior assessment. Another resident’s quarterly MDS indicated antipsychotic medication use but did not check psychotic disorder, even though the POS listed Olanzapine with a diagnosis of psychotic disorder. The MDS Coordinator stated the assessment was not accurate and would need modification and resubmission, and the DON and administrator stated the diagnosis should have been identified on the MDS.
Incomplete Care Plans Failed to Reflect Resident Needs and Preferences
Penalty
Summary
Facility staff failed to develop measurable goals and interventions for comprehensive care plans and failed to update existing care plans to reflect resident care needs for four sampled residents. The facility policy titled Comprehensive Care Plans stated that care planning should include assessment of resident strengths and needs, incorporate personal and cultural preferences, and be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. For one resident, the annual MDS documented cognitive intactness, preferences for music, fresh air, group activities, favorite activities, and religious services, along with diagnoses of asthma, COPD, chronic lung disease, and respiratory failure. The resident’s physician orders included CPAP at bedtime with oxygen, oxygen for saturation below 90% or shortness of breath, and weekly tubing and humidifier changes. The care plan dated 03/25/26 did not document the resident’s activity preferences, oxygen therapy, or CPAP use. Observations showed the resident using oxygen in the room, in the hallway, and during an activity, and the resident stated he/she used oxygen continuously, used CPAP at bedtime, and enjoyed attending activities. For another resident, the significant change MDS showed moderate cognitive impairment, diabetes, seven insulin injections in the prior seven days, and use of a hypoglycemic medication, but the revised care plan did not document diabetes or interventions. A third resident’s comprehensive MDS documented cognitive intactness and preferences for music, news, group activities, favorite activities, fresh air, and religious services, but the care plan did not include those activity preferences or interests. For a fourth resident, the quarterly MDS showed a mechanically altered diet, the dietary slip showed pureed texture, and observations showed the resident eating a lunch meat sandwich in the dining room; the care plan documented a regular diet with pureed texture but did not identify any exceptions for comfort foods.
Lack of Staff-Led Weekend Activities
Penalty
Summary
Facility staff failed to provide an ongoing activity program designed to meet residents’ interests, mental needs, and psychosocial well-being on weekends for three sampled residents. The facility’s policy stated that facility-sponsored group and individual activities, as well as independent activities, would be designed to meet residents’ interests and support physical, mental, and psychosocial well-being while encouraging independence and interaction within the community. However, the February 2026 and March 2026 activity calendars showed limited weekend offerings such as games, puzzles, reading, TV, and church, and staff interviews confirmed there were no staff-led activities on weekends. During interviews, Resident #4, Resident #23, and Resident #28 each stated they enjoyed activities and wanted weekend activities, but said none were provided and they felt bored, lost, or left laying in bed without them. CNA J, LPN F, the activities director, the DON, and the administrator all stated that weekends consisted of puzzles, movies, books, music, or church, and that there were no staff-led weekend activities. The activities director and DON also stated they were not aware that staff-led activities were needed on weekends, and the administrator said they were considering whether an assistant could come in on weekends to do activities.
Missing CPAP Order and Care Plan Documentation
Penalty
Summary
Facility staff failed to provide care and services to meet professional standards for a resident’s CPAP use. The resident had diagnoses including atrial fibrillation, heart failure, high blood pressure, and pneumonia, and the MDS dated 02/25/26 assessed the resident as cognitively intact. The resident’s care plan dated 03/17/26 documented sleep apnea, unspecified, but did not include guidance or information for CPAP use. The Physician Order Sheet for March 2026 did not contain an order for CPAP with the required details such as unit type, pressure settings, frequency of therapy, or cleaning schedule. The medical record also did not include documentation of resident assessment related to CPAP use, including the time and duration of therapy, mode and settings, tolerance of the therapy, or oxygen saturation during therapy. Observations on 03/23/26, 03/24/26, 03/25/26, and 03/26/26 showed the resident’s CPAP on the nightstand. During interview, the resident stated he/she had used CPAP for years and reported that staff sometimes forgot to put water in the machine, causing dry mouth and a burning nose. The resident also stated staff had adjusted the settings when the machine did not feel like it was blowing enough air. Staff interviews confirmed gaps in the resident’s CPAP management. A CNA/CMT stated CPAPs should be on the care plan so staff know when to use them and what to monitor. An LPN stated there should be orders for CPAP, including settings, cleaning, timing of use, and water requirements, and said the resident’s CPAP should be on the care plan. The MDS Coordinator, DON, and Administrator each stated CPAP use should be ordered and included on the care plan, but they did not know the resident had CPAP because no order was present and it was not identified on the MDS assessment or facility equipment list.
Missing Entrapment Assessments for Residents Using Bed Rails
Penalty
Summary
Facility staff failed to complete entrapment assessments for five residents who were using bed rails or assist bars. The facility policy titled Proper Use of Side Rails required assessment of entrapment risk between the mattress and bed rail or within the bed rail itself, regular inspection of mattresses and bed rails for possible entrapment areas, and ensuring the bed frame, bed rail, and mattress did not leave a gap wide enough to entrap a resident's head or body. The policy also assigned the maintenance director or designee responsibility for routine maintenance and inspection of bed frames, mattresses, and bed rails. Resident #11 had moderate cognitive impairment and was documented with an assist bar on the upper left side of the bed, but the medical record did not contain an entrapment assessment. Observations showed the resident in bed with the left grab bar in the upright position on multiple occasions. Resident #32 had moderate cognitive impairment and used grab bars in the upright position on both sides of the bed, but no entrapment assessment was found in the record. Resident #63 was cognitively intact, had bilateral assist rails in the care plan, and was observed in bed with bilateral grab bars upright on multiple occasions, yet the record also lacked an entrapment assessment. Resident #66 had moderate cognitive impairment and was observed in bed with a grab bar in the upright position on the left side of the bed, but no entrapment assessment was documented. Resident #70 had intact cognition and used quarter siderails in the upright position on both sides of the bed, and the record likewise did not contain an entrapment assessment. Interviews showed confusion among the maintenance director, MDS coordinator, DON, and administrator about who was responsible for measuring and completing entrapment assessments, with each describing a different role for maintenance and the MDS staff.
Failure to Use Gait Belt During Transfer Results in Resident Fracture
Penalty
Summary
Facility staff failed to safely transfer a resident, resulting in an accident and injury. Staff did not use a gait belt during the transfer, despite the facility's educational guide directing staff to always use a gait belt for safety. The resident, who was assessed as moderately cognitively intact and required substantial to maximal assistance with transfers, was being moved by two staff members who lifted the resident under the arms and by the clothing, rather than using a gait belt. During the transfer, a popping noise was heard, and the resident sustained a closed fracture of the left femur. The facility's policy on safe lifting and movement did not specify when to use a gait belt, and the resident's care plan did not provide direction regarding gait belt use during transfers. Interviews with staff revealed inconsistent understanding and implementation of safe transfer protocols. One CNA stated they were unsure if a gait belt was required and did not recall receiving in-service training on safe transfers, including during orientation. Other staff, including an LPN and the DON, confirmed that staff are directed to use a gait belt or other transfer equipment, and acknowledged the risk of injury when not using proper equipment. The incident report documented that the staff involved were counseled for not following fall protocol, which resulted in the resident's injury.
Medication Administration Error and Failure to Document
Penalty
Summary
Facility staff failed to administer medications as ordered by the physician when an LPN prepared insulin intended for one resident, but the ADON administered it to a different resident who did not have a physician's order for insulin. The medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, and to document any medication errors in the clinical chart. However, the insulin was prepared for one resident and given to another, and there was no documentation of this medication error in the resident's medical record. The resident who received the insulin was assessed as cognitively intact and had diagnoses including Alzheimer's, hypothyroidism, congestive heart failure, schizophrenia, and diabetes mellitus type II, but did not have a current physician's order for insulin. The error was discovered when the resident's family questioned the administration of insulin, leading to notification of the physician. Interviews revealed that staff were aware of the error but failed to document it as required, and that medication preparation and administration were improperly split between staff due to staffing shortages.
Resident Ingests Another Resident's Medications Due to Medication Cart Error
Penalty
Summary
Facility staff failed to prevent an accident when a resident ingested another resident's medications. The incident occurred when a certified medication technician (CMT) was preparing medications for one resident and placed the cup of medications for a second resident on top of the medication cart. While the CMT was distracted by a request from an LPN to check the LPN's blood glucose, the first resident reached over, picked up the cup containing the second resident's medications, and ingested them. The facility's medication administration policy required staff to verify resident identity three times before administering medication, ensure the right medication, dosage, time, and route, and to keep medications inaccessible to residents by not leaving them on top of the cart. In this case, the CMT did not follow these procedures, as the medications were left on top of the cart and accessible to residents, and the CMT was distracted by another task during medication administration. The resident who ingested the wrong medications was assessed as cognitively intact and independent with ambulation. The medications ingested included Haloperidol, Atorvastatin Calcium, and Clozaril, none of which were ordered for this resident. Following the ingestion, staff assessed the resident, monitored vital signs, and notified the appropriate medical personnel.
Misappropriation of Resident's Controlled Medications by LPN
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's controlled medications when an LPN removed and failed to account for a significant quantity of Oxycodone and Lorazepam. The resident, who was assessed as cognitively intact and experiencing chronic pain with an intensity level of seven, had an active order for Oxycodone-Acetaminophen but no documented order for Lorazepam. Pharmacy records indicated that 120 tablets of Oxycodone were delivered, and upon discharge, staff documented releasing 49 tablets of Oxycodone and 25 tablets of Lorazepam to the resident. Subsequent investigation revealed discrepancies in the medication count and missing medications after the resident's discharge. Video footage showed the LPN removing three medication cards from a locked narcotic box, placing them in the medication cart, and then leaving the medication room with a full card and the medication sign-out sheet. The LPN was later observed disposing of items in a shred bin and trash, which were later identified as the top of the medication card and an empty medication card, respectively. The incident was brought to the facility's attention when the resident's spouse reported missing medications. The DON and administrator reviewed the video footage and confirmed the LPN's actions, which were also documented in a police report. The facility's policy clearly prohibits misappropriation of resident property, including medications, and directs staff to protect residents from such actions by anyone, including facility staff.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility staff failed to maintain proper infection prevention and control practices during wound care and incontinence care for several residents. Specifically, an LPN was observed placing wound care supplies directly on the beds of two residents without establishing a clean field, as required by the facility's policy. In one instance, the supplies were placed on a urine-soaked bed. The LPN acknowledged that supplies should be placed on a clean surface, such as a bedside table, but noted that these tables are often cluttered and inaccessible. Interviews with the Director of Nursing (DON) and the administrator confirmed that wound care supplies should always be placed on a clean barrier. Additionally, the facility staff did not adhere to approved hand hygiene practices during incontinence care. An LPN was observed failing to wash hands or change gloves between dirty and clean tasks while providing perineal care to a resident. Similarly, a CNA did not change gloves or wash hands after handling soiled linens and before touching clean items. Both staff members acknowledged the lapse in proper hand hygiene, and the DON and administrator reiterated the importance of washing hands and changing gloves between tasks to prevent infection. The dietary staff also failed to perform hand hygiene as often as necessary during food preparation and service. Several dietary aides and a cook were observed washing their hands inadequately, scrubbing for only a few seconds, and turning off faucets with bare hands. Despite being trained on proper handwashing techniques, staff admitted to rushing and not following the correct procedures. The Certified Dietary Manager and the administrator confirmed that staff should wash their hands for at least 20 seconds and use a towel to turn off the faucet, highlighting a gap between training and practice.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 25, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan be developed to meet the resident's immediate needs within 48 hours of admission. This plan is intended to be used until a comprehensive assessment and an interdisciplinary person-centered care plan can be developed. However, the medical records for Residents #1, #2, #6, #28, and #65 did not contain these baseline care plans, indicating a lapse in adherence to the policy. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurse (LPN) S, and the administrator, revealed a lack of clarity and accountability regarding the completion of baseline care plans. The DON acknowledged that the baseline care plans should be completed by the admitting nurse as part of the admission process, but noted that the Assistant Director of Nursing (ADON) had been unable to conduct recent chart reviews. LPN S mentioned that baseline care plans are typically completed and reviewed with the medical chart or primary care and family, but was unsure of who was responsible for ensuring their completion. The administrator, who had been at the facility for five months, also stated that the admitting nurse is responsible for completing the care plan, with nursing leadership ensuring its completion, but was unaware of the missing care plans.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific medical and psychosocial needs. For Resident #14, the care plan did not include necessary interventions for oxygen use despite the resident having a diagnosis of respiratory failure and COPD. Observations showed the resident's oxygen concentrator was not being used properly, and interviews with staff revealed a lack of documentation and awareness regarding the resident's oxygen therapy needs. Resident #64's care plan failed to address the resident's contractures, despite observations of the resident's left hand being contracted and causing pain. Interviews with staff indicated that contractures should be documented in the care plan to guide care, but this was not done. Similarly, the care plans for Residents #66, #71, #1, and #17 did not include interventions for their PTSD diagnoses, leaving staff unaware of potential triggers and behaviors to monitor. Additionally, Resident #2's care plan did not include specific instructions for urinary catheter care, leading to inconsistent care practices. Resident #65's care plan lacked details on pressure ulcer prevention and the management of an external fixator, which are critical for the resident's mobility and skin integrity. Interviews with staff and the Director of Nursing highlighted the absence of these essential care components in the care plans, which are necessary for providing appropriate and individualized care to the residents.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility staff failed to document the administration of medications for five residents, as required by the facility's policy. The policy mandates that a Nurse or Medication Aide must document all medications administered to each resident on the Medication Administration Record (MAR) immediately after administration, including the signature and title of the person administering the medication. However, the MARs for several residents showed missing documentation for various medications, including antibiotics, pain relief medications, and nutritional supplements, on multiple occasions throughout August 2024. Interviews with facility staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the absence of a signature on the MAR indicates that the medication was either not administered or not documented. This lack of documentation could potentially lead to residents receiving incorrect dosages. The residents affected by this deficiency had various medical conditions, such as osteomyelitis, arthritis, severe cognitive impairment, and stroke, which required consistent medication management.
Expired Medications Found in Facility
Penalty
Summary
The facility staff failed to remove and destroy expired medications and biologicals in two of four sampled medication carts and one of two medication rooms. Observations revealed that the charge nurse's medication cart contained expired liquid pain relief acetaminophen, and the 400 hall medication cart contained several expired items, including lubricant eye gel, nitroglycerin, fecal occult blood test developing solution, laxative tablets, and a dressing change kit. Additionally, the medication storage room was found to contain expired Novolog insulin Flex Pen and prefilled syringes of influenza vaccines. Interviews with facility staff indicated a lack of consistent procedures for checking and removing expired medications. A Certified Medication Technician mentioned that pharmacy staff used to check for expired medications but no longer do so. The Licensed Practical Nurse stated that nurses and CMTs are supposed to check for expired medications weekly but was unaware of any expired items. The Director of Nursing mentioned that the pharmacist conducts monthly cart audits and that any nurse can dispose of expired medications, yet was unaware of the expired items found during the survey. This lack of awareness and inconsistent practices contributed to the presence of expired medications in the facility.
Failure to Address Resident's Contracture and ROM Needs
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM) for a resident with a contracture in the left hand. The facility's policy required that residents with limited ROM receive treatment to prevent further decline, and that care plans include specific interventions and therapies. However, the resident's care plan did not document the contracture, goals, or interventions, despite the resident's hospital discharge documentation indicating the need for occupational therapy focused on contracture prevention. Observations over several days showed the resident's left hand remained contracted without any intervention, such as a washcloth, which the resident reported as helpful. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and action regarding the resident's contracture. Staff did not perform ROM exercises or provide any therapy, and there was no communication or documentation in the care plan regarding the contracture. The Director of Nursing (DON) acknowledged the oversight, stating that the contracture should have been included in the care plan and communicated to the MDS Coordinator. The DON also noted that physical therapy determines who receives restorative services, but there was no indication that the resident had been evaluated for such services. The lack of documentation and communication led to the resident not receiving necessary interventions for the contracture.
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What surveyors actually found near you
We read the 35 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Owensville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gasconade Manor Nursing Home | 2.7 mi | ★★★★★ | 0 | 0 |
| Cuba Manor Inc | 19.4 mi | ★★★★★ | 15 | 0 |
| Life Care Center Of Sullivan | 20.6 mi | ★★★★★ | 11 | 0 |
| Meramec Nursing | 21.4 mi | ★★★★★ | 0 | 0 |
| St James Living Center | 23.1 mi | ★★★★★ | 8 | 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 August 2026) and official state health department websites.