Below 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 Villa Marie during CMS and state inspections, most recent first.
Staff failed to remove expired, undated, and improperly labeled medications from medication carts and a medication room, including multiple insulin pens, eye drops, calcium, and TB solution. An LPN administered expired Novolog insulin to a resident without checking the expiration date, and interviews confirmed that opened insulins, eye drops, and TB solution should be dated and checked before use.
Facility staff failed to use EBP for several residents with wounds or an unhealed surgical site. Observations showed no EBP signage or PPE outside the rooms, and wound care was provided by an LPN and CNA without gowns for two residents. Records showed the affected residents had wounds, an ostomy-related surgical wound, or other skin openings, while care plans did not document EBP. Interviews with the IP, DON, administrator, LPNs, and CNA showed confusion about when EBP was required and who was responsible for posting signs and placing PPE.
Incomplete Care Plans for Wound, Ostomy, and Oxygen Needs: Facility staff failed to develop comprehensive, person-centered care plans for two residents. One resident had venous ulcers and wound care orders, but the care plan did not include EBP use. Another resident had an unhealed surgical wound, an ostomy, and continuous O2 orders, but the care plan did not include EBP use or O2 directions. The DON, MDS Coordinator, Administrator, and IP all stated these needs should have been included on the care plans.
Care plans were not kept current for four residents with changing needs. One resident with severe neurologic impairment and contractures had an order for arm and leg braces, but the care plan did not include splints or contractures and the resident was observed without them. Another resident’s care plan was not updated after psychotropic meds were discontinued, while a third resident’s plan did not address a recent fall with injury or refusals of care. A fourth resident’s plan did not include direction for ongoing antipsychotic use, and staff interviews confirmed these items should have been on the care plans.
A resident with stroke-related cognition concerns, resistive behavior, and multiple falls had several unwitnessed falls documented without evidence of required neuro checks, and two additional falls were charted without stating whether they were witnessed or unwitnessed. Facility policy required staff to document fall details and complete neuro assessments after unwitnessed falls or suspected head injury, but the record lacked the required documentation.
Missing BiPAP Orders for Resident Using Respiratory Support: A resident with respiratory failure and obstructive sleep apnea had BiPAP therapy listed on the care plan, and a BiPAP machine was observed at the bedside on multiple occasions, but the POS did not contain BiPAP orders. The IP/charge nurse, DON, and administrator all stated the resident should have BiPAP orders, and the DON noted the orders were needed so staff would know the BiPAP settings.
Missing Physician Orders for Side Rail Use: Two cognitively intact residents had both upper side rails in the upright position, but their POS did not contain physician's orders for side rail use. Facility policy required an order for the specific side rails and the related diagnosis, condition, symptoms, or functional reason. The IP was unaware the orders were missing, while the DON and Administrator stated the charge nurse was responsible for obtaining and documenting orders and the DON was responsible for oversight.
Failure to post required state hotline information: Facility staff did not have the DHSS Elder Abuse Hotline or State Survey Agency contact information posted in an accessible location on the memory care unit for residents and visitors. Observations showed the information was not posted where residents or visitors could use it, and a CNA, an LPN, the DON, and the administrator all indicated the hotline was not visible on the unit or were unsure whether it was posted there.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not complete the care plan within 7 days of the comprehensive assessment and failed to ensure it was prepared, reviewed, and revised by a team of health professionals as required.
A facility failed to thoroughly investigate a sexual assault allegation involving a resident with severe cognitive impairment. The investigation lacked signed statements from staff or witnesses and did not include interviews with other residents, contrary to the facility's policy. The DON initiated the investigation, but documentation was incomplete and stored on the DON's computer, who was off work. The LPN who reported the allegation was not asked to provide a signed statement.
Facility staff failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment to DHSS and law enforcement within the required two-hour timeframe. Despite the facility's policy, the DON and administrator delayed reporting, as they did not find the allegation substantiated after an internal investigation. The resident had reported the incident to an LPN, who informed the administrator and DON immediately.
The facility failed to employ a full-time qualified dietitian or nutrition professional, resulting in the appointment of an unqualified dietary manager (DM) without prior experience or necessary certification. The DM had not started the required training, and the facility's registered dietitian only works part-time, potentially affecting all 66 residents.
Facility staff failed to serve food according to nutritionally calculated menus, as observed during a survey. Dietary staff did not prepare or serve cream cheese brownies as directed for residents on regular and dental/mechanical soft diets. Additionally, residents on pureed diets were served unmeasured portions of pureed leftovers instead of the specified menu items. This practice was due to training by a previous dietary manager, and the current dietary manager continued this without realizing it was against menu directives. The facility administrator was unaware of the non-compliance.
The facility staff failed to store food properly, leading to potential contamination and outdated use. Observations showed unlabeled and undated food items, improper thawing of frozen foods, and inadequate hand hygiene and dishwashing practices. The dietary manager and administrator acknowledged these issues, citing a lack of training and oversight as contributing factors.
The facility did not designate a qualified Infection Preventionist (IP) for its infection prevention and control program. The LPN/ADON enrolled in IP training only after the DON resigned, leaving the facility without a trained IP since April. The facility lacked a policy on IP qualifications, and the ADON and another RN are now enrolled in training.
The facility failed to complete required PASARR screenings for three residents, despite their significant cognitive impairments and psychiatric diagnoses. The residents, who were admitted or transferred from other facilities, did not have the necessary Level I Pre-Admission Screening or PASARR Level II screen. Interviews with staff revealed that the new administrator and SSD faced challenges in reviewing and locating PASARR records due to staff turnover and other priorities.
Facility staff failed to maintain safe food temperatures, serving hot food items like hamburger patties and french fries below the required 140°F, and pureed foods below 165°F. Staff did not check temperatures before serving, contrary to facility policies, risking food-borne illness for residents.
Facility staff failed to prepare and serve food at the correct texture for residents on mechanical soft diets. Instead of grinding hamburger patties as required, the cook diced them, following incorrect training from the DM. This led to a resident coughing after eating the meal. The DM and administrator were unaware that staff were not following the correct portion sizes and preparation methods.
Improperly Labeled and Expired Medications Found in Carts and Medication Room
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with facility policy and accepted principles when staff failed to remove discontinued and improperly labeled medications from medication carts and a medication room. Surveyors observed the rehabilitation medication cart with multiple medications that were expired, undated, or improperly labeled, including Oyster Shell Calcium with an expiration date of 11/25, several insulin pens with open dates but expired use dates or no dates, and Systane eye drops that were opened and undated. The Memory Care Unit medication cart also contained multiple insulin pens that were open and undated, and the Memory Care Unit medication room contained a vial of TB solution with an open date of 08/01/25. During observation, an LPN administered Novolog insulin to a resident without checking the expiration date, even though the pen had an open date of 02/11/26 and an expiration date of 03/11/26. The LPN stated the expiration date was not checked before administration and should have been. Interviews with the LPN, Infection Preventionist, DON, and administrator confirmed that staff who open medications are responsible for dating them, that insulins, eye drops, and TB solution should be dated when opened, that staff should check expiration dates before administration, and that expired medications should be removed and destroyed. The report also noted that the facility census was 62.1.
Failure to Use Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
Facility staff failed to use enhanced barrier precautions (EBP) for four sampled residents who had wounds or an unhealed surgical site. The facility policy dated 04/04/24 stated EBP was to be used to prevent transmission of multidrug-resistant organisms and required gowns and gloves for high-contact resident care activities for residents with wounds or indwelling medical devices. The policy also stated clear signage was to be posted outside the room and PPE made available immediately outside the room. In the cases reviewed, the care plans for the affected residents did not contain direction for EBP use, and observations repeatedly showed no EBP sign and no PPE inside or outside the rooms. Resident #1 had venous ulcers on the left lower extremity and foot, with physician orders for daily wound care and dressing changes. The resident was observed multiple times with the left lower extremity wrapped in a bandage, but the room did not have an EBP sign or PPE available. The Infection Preventionist stated the resident’s lower extremities swell and cause fluid-filled blisters that weep and open, and the administrator stated the resident should have been on EBP due to chronic wounds on the left lower extremity. Resident #5 had severe cognitive impairment, diabetes, dementia, anxiety, depression, psychotic disorder, and wounds to the left gluteal cleft and left ischium. The resident’s care plan did not document the need for EBP. Observations showed no EBP sign and no PPE outside the room. During wound care to the left ischium, an LPN and CNA assisted without wearing a gown. Resident #20 had a right hand wound with an order for antimicrobial foam dressing, and the care plan did not document EBP. Observations again showed no EBP sign or PPE, and during wound care an LPN and CNA did not wear a gown. Staff interviews reflected confusion about when EBP was required, with some staff stating it applied only to wounds present for 90 days or more. Resident #28 had an ostomy and an abdominal midline wound with an order for wound care and dressing changes. The resident stated the ostomy was newer and had not healed completely. Observations showed no EBP sign and no PPE outside the room. The Infection Preventionist and administrator stated the resident should have been on EBP due to an unhealed surgical wound site. Interviews with the IP, DON, administrator, LPNs, and CNA showed inconsistent understanding of EBP criteria and uncertainty about who was responsible for posting signs and placing PPE supplies.
Incomplete Care Plans for Wound, Ostomy, and Oxygen Needs
Penalty
Summary
Facility staff failed to develop comprehensive, person-centered care plans that reflected the care needs of two residents. The facility policy required care plans with measurable objectives and timetables, developed and updated by the interdisciplinary team, and revised when resident conditions changed or at least quarterly. Review of one resident’s quarterly MDS showed cognitive intactness with wounds, but the care plan only identified risk for skin breakdown with venous ulcers on the left lower extremity and foot and did not include direction for EBP use. Physician orders showed daily wound care for the left foot and left lower extremity, and observations showed the resident in a wheelchair with the left lower extremity wrapped in a bandage. The Infection Preventionist stated the resident had fluid blisters that wept and popped open. For the second resident, the admission MDS showed cognitive intactness, a surgical wound, and oxygen therapy. The care plan identified chronic pain related to a surgical non-healing wound and an ostomy with need for assistance, but it did not include direction for EBP use or oxygen use. Physician orders showed continuous oxygen at 3 liters per nasal cannula, ostomy pouch changes every three days and at the first sign of a leak, and wound care for an abdominal surgical wound. Observations showed the resident wearing oxygen and an ostomy pouch hanging out from under the shirt, and the resident stated the ostomy had not healed completely and the skin was irritated. The IP stated the resident had an unhealed surgical wound for the ostomy site and should have an EBP care plan, and that the resident required continuous oxygen and should have an oxygen care plan.
Care plans not updated to reflect residents’ current care needs and treatments
Penalty
Summary
Facility staff failed to update care plans for four sampled residents to reflect current care needs and treatment changes. The facility policy stated care plans should be comprehensive, person-centered, and revised when a resident’s condition changes, when desired outcomes are not met, and at least quarterly with the MDS. Surveyors found that the care plans for Residents #6, #7, #20, and #43 did not match the residents’ current assessments, physician orders, or observed care needs. Resident #6 was assessed as being in a persistent vegetative state, dependent for all care and mobility, with limited range of motion, traumatic brain dysfunction, hemiplegia, and aphasia. The resident had an order for leg and arm braces during the day and night shift for contractures, but the care plan dated 12/26/25 did not document contractures or splint use. During observation, the resident was in bed without splints on. Staff interviews indicated the splints should have been on the care plan so staff would know to provide them. Resident #7’s annual assessment showed severe cognitive impairment and use of antipsychotic and antidepressant medications, but the March 2026 POS did not include current orders for those medications and the care plan did not document their discontinuation. Resident #20’s assessment showed a fall since the prior assessment, one fall with injury, hemiplegia, aphasia, dementia, and dependence for mobility, yet the care plan did not include an intervention for the 02/25/26 fall or direction regarding refusal of care. Resident #43’s assessment showed moderate cognitive impairment and use of an antipsychotic medication, and the POS listed Abilify 2 mg daily, but the revised care plan did not contain direction for antipsychotic medication use. Interviews with nursing staff, the DON, the MDS Coordinator, and the Administrator confirmed that contractures, splints, falls, psychotropic use, and refusals of care should be reflected in the care plans.
Failure to Document Falls and Neurological Checks
Penalty
Summary
Facility staff failed to document falls and neurological assessments for one resident with a history of stroke-related cognition concerns, resistive behavior with care, assistance needs, and multiple documented falls. The resident's quarterly MDS dated 02/27/26 identified the resident as cognitively intact and having falls with injury. The care plan revised 03/06/26 noted cognition concerns related to a stroke, resistive to care, required assistance with cares, and risk for falls with multiple falls documented. The medical record showed multiple unwitnessed falls on 01/24/26, 02/02/26, 02/09/26, 02/21/26, 03/05/36, and 03/06/26, with no documentation that neurological checks were completed. Two additional falls on 03/06/26 and 03/10/26 were documented without stating whether the falls were witnessed or unwitnessed and without completed neurological checks. Facility policy required staff to document whether a fall was witnessed or unwitnessed and to complete neurological assessments after unwitnessed falls or suspected head injury, and the facility's post-fall monitoring form required specific monitoring intervals and documentation elements. During interviews, the IP/charge nurse, DON, and administrator stated that falls should be documented with details and that neurological checks should be completed for unwitnessed falls or head injuries, but the administrator said he/she was not aware that not all fall documentation and neurological checks were being completed.
Missing BiPAP Orders for Resident Using Respiratory Support
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when facility staff failed to obtain orders for a BiPAP for Resident #2. The resident’s Significant Change MDS dated 02/17/26 identified the resident as cognitively intact with diagnoses of respiratory failure and obstructive sleep apnea. The resident’s care plan, revised 02/21/26, included BiPAP therapy per orders, but the Physician Order Summary dated 03/10/26 did not contain BiPAP orders. Observations on 03/10/26, 03/11/26, 03/12/26, and 03/13/26 showed a BiPAP machine next to the resident’s bed. During interviews, the IP/charge nurse stated the charge nurse was responsible for obtaining and documenting resident orders on the POS and said the resident should have BiPAP orders. The DON stated the charge nurse was responsible for obtaining the orders and placing them on the POS, acknowledged the resident used BiPAP, and said the orders were needed so staff would know the BiPAP settings. The administrator stated the DON was responsible for overseeing the charge nurse to ensure residents had correct orders to meet their care needs and said the resident should have BiPAP orders.
Missing Physician Orders for Side Rail Use
Penalty
Summary
Failure to obtain physician's orders for the use of side rails was identified for two residents. The facility policy titled Proper Use of Side Rails, revised 09/22, stated the facility would obtain a physician's order for the specific side rails and the medical diagnosis, condition, symptoms, or functional reason for their use. Resident #2's Significant Change MDS showed the resident was cognitively intact, and the care plan revised 02/21/26 documented that a physician's order would be current for side rails to be used. However, the POS dated 03/10/26 did not contain an order for side rail use, while observations on 03/11/26, 03/12/26, and 03/13/26 showed both upper side rails in the upright position on the resident's bed. Resident #23's Quarterly MDS also showed the resident was cognitively intact, and the care plan revised 01/18/26 stated a physician's order would be current for side rails to be used. The POS dated 03/10/26 did not contain an order for side rail use, yet observations on 03/10/26, 03/11/26, and 03/12/26 showed both upper side rails up on the resident's bed. During interviews, the IP said he/she was not aware the residents did not have orders for side rails and stated they should have an order on the POS. The DON said the charge nurse was responsible for obtaining orders and documenting them on the POS, and the Administrator said the charge nurse was responsible for new orders and the DON was responsible for overseeing that residents had correct orders to meet their care needs.
Failure to Post Required State Hotline Information
Penalty
Summary
Facility staff failed to post the required telephone number to the DHSS hotline for reporting allegations of abuse and neglect, or a list of names, addresses, and phone numbers of the State Survey Agency, in an accessible location for residents and visitors to view in the memory care unit. The facility's policy titled, Facility Postings, stated that required postings would be placed in an area accessible to all staff and residents and would include a list of names, addresses, and telephone numbers of pertinent state agencies, including the SA. Observations on 03/10/26 at 10:30 A.M. and 03/13/26 at 11:00 A.M. showed the name, address, and toll-free telephone number for the Elder Abuse Hotline were not posted in an accessible location on the memory care unit for residents or visitors to use if needed. During interviews, a CNA said he/she was unsure whether the hotline number was posted on the memory care unit and stated the information was posted in the employee break room, while an LPN said he/she did not remember seeing the hotline number posted on the memory care unit. The DON and administrator both said they did not know if the hotline number was posted on the memory care unit, but both stated it should be visible for residents and visitors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Incomplete Investigation of Sexual Assault Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident with severe cognitive impairment, dementia, traumatic brain injury, and anxiety disorder. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and documentation of all allegations, including interviews with the involved resident, witnesses, and other residents. However, the investigation report lacked signed and dated statements from staff or witnesses and did not document interviews with other residents. The Director of Nursing (DON) was notified of the allegation by an LPN and initiated an investigation, but the documentation was incomplete and stored on the DON's computer, who was off work at the time. The administrator confirmed that the DON and Assistant Director of Nursing (ADON) gathered most of the information, but the LPN who reported the allegation was not asked to provide a signed statement. This lack of thorough documentation and adherence to the facility's policy led to the deficiency.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident to the Department of Health and Senior Services (DHSS) and local law enforcement within the required two-hour timeframe. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours if the events involve abuse or result in serious bodily injury. Despite this, the Director of Nursing (DON) and the administrator did not report the allegation within the specified timeframe, as they did not find the allegation substantiated after an internal investigation. The resident involved was assessed with severe cognitive impairment and had diagnoses including dementia, traumatic brain injury, and anxiety disorder. The resident reported the alleged sexual assault to a Licensed Practical Nurse (LPN), who immediately informed the administrator and the DON. However, the DON did not report the incident to DHSS within the required timeframe, as the internal investigation did not substantiate the claim. The Assistant Director of Nursing (ADON) confirmed awareness of the initial report and acknowledged the requirement to report such allegations within two hours, but was unsure why the report was delayed.
Lack of Qualified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The facility's Food Services Manager policy requires the daily functions of the Food Services Department to be under the supervision of a qualified Food Services Manager. However, the current dietary manager (DM) was hired without prior experience in a nursing facility and lacked the necessary certification or education for the director of nutritional services position. The DM had been in the position for about two weeks and had not yet started an online food protection manager's course. The administrator admitted to hiring the current DM from within the dietary department after the previous DM quit without notice. The facility's registered dietitian only works part-time, and there are no certified or clinically qualified nutritional staff employed full-time. The administrator was unaware that the DM did not meet the requirements for the position, which has the potential to affect all residents in the facility, with a census of 66.
Failure to Follow Nutritionally Calculated Menus
Penalty
Summary
The facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents, as observed during a survey. The facility's policy, dated October 2008, required that menus meet the nutritional needs of residents, be prepared in advance, and be followed. However, on a specific day, dietary staff did not prepare or serve cream cheese brownies as directed by the menus to residents on regular and dental/mechanical soft diets. The dietary manager acknowledged the oversight and admitted to not knowing why the brownies were not made. Additionally, the facility staff did not follow the menu for residents on pureed diets. Instead of serving the specified pureed cheeseburger, french fries, mandarin oranges, and cream cheese brownie, staff served unmeasured portions of pureed leftover roast beef, green beans, and cinnamon rolls. This practice was a result of training by the previous dietary manager, who instructed staff to use leftovers for pureed meals. The current dietary manager continued this practice, unaware that it was against the menu directives. The facility administrator confirmed that staff should follow the planned menus and was unaware that the menus were not being adhered to.
Deficiencies in Food Storage, Thawing, and Hygiene Practices
Penalty
Summary
The facility staff failed to store food in a manner that prevents potential contamination and outdated use, as observed during a survey. Multiple instances were noted where food items in refrigerators and storage areas were unlabeled, undated, and left open to the air, which could lead to cross-contamination and the growth of food-borne pathogens. The dietary manager acknowledged that staff were trained on proper food storage practices, but some staff continued to neglect these protocols. The administrator confirmed that all dietary staff are responsible for monitoring food storage, but the dietary manager is specifically tasked with weekly checks. Additionally, the facility staff did not adhere to proper thawing procedures for frozen foods, as evidenced by the observation of frozen broccoli florets left on a countertop next to ready-to-eat food items. The dietary manager admitted that the broccoli should not have been left on the countertop and should have been thawed in the refrigerator or under running water. The administrator reiterated that staff were trained on proper thawing techniques, but the issue persisted due to a lack of oversight and training. The facility also failed to ensure proper hand hygiene and dishwashing practices. Observations revealed that staff did not allow dishes to air dry before stacking them, and several staff members did not follow proper handwashing procedures, such as scrubbing hands for the required duration or using paper towels to turn off faucets. The dietary manager and administrator both acknowledged these deficiencies, noting that some staff had not been adequately trained on these requirements. Furthermore, waste containers were left uncovered, contrary to the facility's policy, which could attract pests and rodents. The dietary manager admitted to not having trained all staff on this requirement, and the administrator confirmed that waste containers should always be covered.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) for its infection prevention and control program, as required. The facility, with a census of 66, did not have a policy outlining the qualifications for the IP role. During interviews, it was revealed that the Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) had only recently enrolled in the necessary IP training after the Director of Nursing (DON) resigned. The DON had been enrolled in IP training since April but had not completed it before resigning. Consequently, the facility had been without a trained IP since April, and the ADON and another Registered Nurse (RN) were only now enrolled in the training to serve as backups.
Failure to Complete PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure that Level I Pre-Admission Screening and Resident Review (PASARR) screenings were completed for three of the seven sampled residents. The PASARR process is a federally mandated screening to evaluate the presence of psychiatric conditions and determine if a Level II screen is required. The facility's policy outlines specific procedures for obtaining and processing the necessary forms, DA-124 A/B, for residents in Medicaid-certified beds. However, the facility did not adhere to these procedures, resulting in the absence of required screenings for the residents in question. Resident #25 was admitted and re-entered the facility without a Level I Pre-Admission Screening or PASARR Level II screen, despite having diagnoses of dementia, depression, and schizophrenia, and receiving psychiatric medications. Similarly, Resident #48, who entered from an inpatient psychiatric facility, and Resident #59, who transferred from another skilled nursing facility, both lacked the necessary PASARR evaluations. These residents had significant cognitive impairments and psychiatric diagnoses, which should have triggered the need for a PASARR assessment. Interviews with facility staff revealed that the administrator, who started in March, acknowledged a lack of review of PASARRs due to other priorities. The Social Services Director (SSD), who is new to the position, admitted difficulty in locating and reviewing the PASARR records for current residents. The SSD stated that while all new residents have complete PASARRs, the records for existing residents have been challenging to find, indicating a lapse in the facility's compliance with PASARR requirements.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility staff failed to ensure that prepared food items were served at a safe and appetizing temperature. Observations revealed that hot food items, such as hamburger patties and french fries, were not maintained at the required internal temperature of 140°F or higher. The staff did not check the internal temperatures of these food items before placing them in insulated food carts for delivery to the dining room. When the food was served, the internal temperatures of the hamburger patties and french fries were significantly below the safe temperature, measuring as low as 116°F and 93°F, respectively. Additionally, the facility staff did not reheat pureed food items to the necessary internal temperature of 165°F before service. Pureed foods, including roast beef, green beans, and cinnamon rolls, were observed to be served at temperatures as low as 74°F, which is well below the safe threshold. The dietary aide admitted to not checking the internal temperatures of foods before serving them, and the dietary manager was unaware that staff were not following the proper procedures for temperature checks. The facility's policies on food preparation and service, as well as food safety requirements, were not adhered to by the staff. These policies clearly outline the importance of maintaining food temperatures to prevent the growth of food-borne pathogens. Despite recent education on food temperature requirements, the staff failed to implement these practices, leading to the potential risk of food-borne illness for all residents dining in the affected dining room.
Improper Food Preparation for Mechanical Soft Diets
Penalty
Summary
Facility staff failed to prepare and serve food items at an appropriate texture for residents on dental/mechanical soft diets. The facility's policy required that menus meet the nutritional needs of residents and that standardized recipes be used. However, the staff did not follow these guidelines. Instead of grinding hamburger patties as directed by the recipe, the cook cut them into small diced pieces. This method of preparation was taught by the dietary manager (DM), who had been trained by the previous DM to cut food items with a knife for mechanical soft diets, despite the recipe's instructions to use a food processor. During meal service, residents received a smaller portion of diced hamburger patties than specified in the menu. One resident began coughing repeatedly after consuming the meal, indicating that the food texture was inappropriate. The DM acknowledged that not all residents on mechanical soft diets could make choices about food texture and admitted to not knowing that staff were not following the portion sizes on the menu. The administrator confirmed that food should be prepared and served according to the planned menus and recipes, and was unaware that staff were not adhering to these standards.
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 144 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capitol River Wellness & Rehabilitation | 0.5 mi | ★★★★★ | 13 | 0 |
| Stonebridge Adams Street | 0.8 mi | ★★★★★ | 4 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 1 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 1.1 mi | ★★★★★ | 12 | 0 |
| Jefferson City Manor Care Center | 1.4 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.