3105 Bluff Creek Drive, Columbia, MO 65201 · Boone County · (573) 442-6060
132 certified beds, about 118 residents a day · Non profit - Corporation · Medicare and Medicaid since 1992
CMS Care Compare ratings, data as of September 1, 2026 · CCN 265498 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 30, 2026, inspectors cited 13 health deficiencies (the Missouri average is 11.4, the national average 9.2).
Of 41 health citations since June 2023, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 3 fines totaling $37,621 in the last three years; the largest was $19,401, and the latest is dated January 14, 2025.
Nurses and nurse aides worked 4.20 hours per resident per day, against 3.43 across Missouri and 3.86 nationally. Registered nurses accounted for 0.59 of those hours.
61.8% of nursing staff left within the year CMS measured (Missouri average 56.0%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 41 health citations on file.
Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to ensure wound care orders were in place for one resident (Resident #123), failed to follow wound care orders for one resident (Resident #7), failed to follow orders for wrist splints to prevent or maintain contractures for one resident (Resident #19), and failed to complete neurological assessments after falls for two residents (Resident #103 and #63), out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff in regard to physician's orders.2. [...]
Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 115.1. Review of the facility lunch menus, dated 01/28/26 (Week 1, Day 4), showed the menus directed staff to provide the residents who receive pureed diets with a: -#8 (four ounces (oz.)) scoop of pureed barbequed pork;-#8 scoop of mashed potatoes with thick gravy;-#10 (3.2 oz.) scoop of pureed spinach;-#16 (two oz.) scoop of pureed dinner roll with margarine. Observation on 01/28/26 during the lunch meal service which began at 11:24 A.M., showed staff served the residents who received pureed diets with #10 scoops of pureed barbequed pork and mashed potatoes and a #12 (2.6 oz.) scoop of pureed spinach (less than directed by the menus). [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to preform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of foodborne pathogens. These failures have the potential to affect all residents. The facility census was 115.1. Review of the facility's Hand Hygiene & Glove Changes policy, dated 06/01/24, showed All staff members shall practice hand hygiene and glove changes in accordance with these procedures and applicable standards of practice to reduce the spread of infections and prevent cross-contamination. Review showed the policy directed staff to apply soap and, using friction, rub hands together for at least 30 seconds when they washed their hands and to wash their hands, at a minimum, when: [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to develop and review the program, policies and procedures annually. Facility staff failed to use enhanced barrier precautions ((EBP) - infection control intervention designed to reduce transmission of multi-drug-resistant organisms), and/or failed to have EBP signs posted, perform appropriate hand hygiene and glove changes during wound care for three residents (Resident #7, #103, and #123) out of three sampled residents, catheter care for one resident (Resident #8) of two sampled residents. [...]
Inspectors wroteBased on interview and record review, 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 census was 115.1. Review of the facility's policy titled, Antibiotic Stewardship Program, revised 10/30/18, showed the objective: to promote the highest possible quality of care by optimizing the treatment of infections while reducing unnecessary laboratory tests and antibiotic use through promotion of antibiotic stewardship principles and development of activities aimed at improving jhow antibiotics are used and prescribed. Review showed:-Policy: Antibiotic Stewardship is a set of commitments and actions intended to optimize the treatment of infections while reducing adverse events associated with antibiotic use. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered COVID-19 (an infectious disease caused by the SARS-CoV 2 virus) vaccination, that education was provided regarding the benefits and risks of the COVID-19 vaccine and signed consent, or refusal obtained from the resident or the resident's representative, for four residents (Residents #7, #19, #21, and #28) out of five sampled residents and for three staff members (Director of Food Services, Certified Nurse Aide (CNA) B and Resident Service Assistant (RSA) C) of three sampled staff members. The facility census was 115.1. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over four residents (Residents #58, #78, #34 and #19) of 27 sampled residents as they fed them during mealtime. The facility census was 115.1. Review of the facility's Nursing Home Residents' Rights policy, undated, showed residents have a right to a dignified existence; to be treated with consideration, resident, and dignity, recognizing each resident's individuality; quality of life maintained or improved; and a homelike environment. Review of the facility's policies showed staff did not provide policy for staff assisting residents at mealtime. 2. [...]
Inspectors wroteBased on interview and record review, facility staff failed to document residents' code status (Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation (CPR)) consistently for two residents (Resident #2, and #100). The facility census was 115.1. Review of the facility's policies showed did not contain a policy for advance directives or resident code status. 2. Review of Resident #2's Electronic Medical Record (EMR) Face Sheet, showed the resident admitted to the facility on [DATE] with a code status as DNR. Review of the resident's Physician Order sheet (POS), dated 12/2025, showed the physician signed an order for Full Code status. Review of the resident's Care Plan, dated 12/2025, showed staff documented the resident as DNR status. Observation of the resident's door showed a red dot by the resident's name indicated a code status of DNR. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to notify the physician or registered dietician of the refusal of nutritional supplements for one resident (Resident #44), and failed to obtain a nutritional supplement in a timely manner for one resident (#61), out of 27 sampled residents. The facility census was 115.1. Review of the facility's policies did not contain a policy to direct staff on when to notify the physician or dietician if a resident refuses prescribed supplements or a policy on when to obtain a physician's order for supplements.2. Review of Resident #44's quarterly Minimal Data Set (MDS), a federally mandated assessment tool, dated 12/10/25, showed staff assessed the resident with impaired cognition, and weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months. [...]
Inspectors wroteBased on interview and record review, facility staff failed to screen five employees (Director of Food Services, Resident Service Assistant (RSA) D, RSA C, Dietary Aide (DA) CC and Licensed Practical Nurse (LPN) FF) out of ten new employees prior to employment to determine if the employees had any indicators on the Certified Nurse Aide (CNA) Registry. The facility census was 115. 1. Review of the Facility's policy titled, Abuse & Neglect, dated 05/31/24, showed the facility will not employ individuals who have had a finding entered the Missouri CNA Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for six residents (Resident #7, #8, #19, #61, #78 and #103) out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff when to review or revise care plans. 2. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/26, showed staff assessed the resident as:-Moderate cognitive impairment;-One or more unhealed pressure ulcers;-Two unstageable pressure ulcers. Review of the resident's progress notes, dated 12/02/25, showed staff documented the resident seen by wound clinic for two unstageable pressure ulcers to bilateral heals. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner when staff failed to discard expired medications/supplies for two out of five medication carts, and one of three medication storage rooms. The facility census was 115.1. Review of the facility's Storage and Labeling of Drugs Policy, dated 12/02/13, showed nursing staff shall check all stock medications routinely (no less than monthly) for expired medications the need for restocking and that the stock be rotated. Central supply staff or Director of Nursing (DON) Designee is responsible for checking expiration dates of all stock medication at least monthly. As new stock medications are brought in, stock is rotated to ensure oldestsamples are at the front. Expired medications are to be destroyed through use of drug buster. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store medications in the memory care unit bathroom and left medications in one resident's bathroom (Resident #62). The facility census was 115.1. Review showed the facility failed to provide a policy to direct staff on medication storage safety. 2. [...]
Inspectors wroteBased on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital with low blood sugar. The facility census was 116. The administrator was notified on [DATE] of past Non-Compliance, which occurred on [DATE] when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on [DATE]. 1. Review of the facility Medication Administration policy, dated [DATE], showed nursing personnel shall ensure the safe and effective administration of medications. [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident (Resident #1) in a manner to prevent accidents when staff failed to lower the resident appropriately in the shower chair which resulted in a compression fracture (a break in a vertebra, or bone in your spine, causes it to collapse) the resident's spine. The facility census was 115. 1. Review of the facility's use of lift machine policy, dated 11/25/2019, showed the purpose of the policy is to help lift residents who otherwise may not be transferred manually, promote comfort and maintain good body alignment while resident is being moved, to position the resident in desired location, and use controls to slowly lower resident to that location. 2. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to follow standard universal infection control precautions when staff used one insulin pen on three residents (Resident #7, #10, and #41), possibly creating a risk of bloodborne and bacterial pathogen transmission. The facility failed to use appropriate hand hygiene infection control practices during perineal and wound care for four (# 41, #43, #47, #105) of four sampled residents, and failed to follow Enhanced Barrier Precautions (EBP), the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms, for three (#7, #19, and #105) of four sampled residents. The facility census was 117. The administrator was notified on 10/31/24 at 8:00 A.M., of an Immediate Jeopardy (IJ) which began on 10/28/24. [...]
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms in clean and good repair. The facility census was 117. 1. Review of the facility's Work Order Policy, dated 01/10/24, showed when staff noticed maintenance or repair needs, they should report this to their immediate supervisor, the charge nurse, or a member of the leadership team. 2. Observation on 10/28/24 at 11:40 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom floor with a ripped area at the shower stall. Stained floor trim that was pulled away from the wall by the shower.i Observation on 10/28/24 at 2:31 P.M., showed resident occupied room [ROOM NUMBER]'s wall behind the bed with multiple areas of gouged and chipped paint. [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for four of four sampled residents (Resident #19, #48, #69, and #115). The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed the following: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Staff did not document they notified the resident or resident representative of the transfer in writing. 3. Review of Resident #48's medical record showed the following: -Transferred to Emergency Department on 10/9/24 with return anticipated; [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two (Resident #19 and #69) of three sampled residents. The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed staff documented the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -Staff did not document they notified the resident or the resident representative of the bed hold policy in writing. 3. [...]
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to develop comprehensive care plans with resident-specific interventions to meet the resident's preferences and goals, and to address the resident's medical, physical, and psychosocial needs for five residents (Residents #45, #49, #56, #108, and #111) out of twelve sampled residents. The census was 117. 1. Review of the facility's policies showed the facility did not provide a policy for care plans. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/24, showed staff assessed the resident as: -Cognitively impaired; -Had inattentive and disorganized thinking that fluctuated; -No behaviors or wandering; -Diagnosis of dementia. Review of the resident's nurse notes, dated 08/28/24 through 10/28/24 showed staff documented: [...]
Inspectors wroteBased on observation, interview and record review, staff failed to document neurological checks after a fall for one (Resident #119) per facility policy, failed to document the removal of medication patches and the location of the new patch for one resident (Resident #48) who received Exelon Patches (to treat Alzheimer's disease) per facility policy and failed to document an indication for use on medications for seven (Resident #31, #45, #72, #87, #99, #111, and #324) of seven sampled residents. The facility census was 117. 1. Review of the facility's fall policy, dated October 2021, showed a fall is defined as an unintended change in position coming to rest on the ground or onto the succeeding lower surface and can occur while walking, standing, lying in bed and sitting. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer two residents (Residents #26 and #81) of three sampled residents by mechanical lift in a manner to prevent accidents. Facility staff failed to safely propel two residents (Resident #50 and #24) in a wheelchair and failed to properly secure medication in two treatment carts on the secured unit and the 500 hall. The facility census was 117. 1. Review of the facility's Use of Lift Machine policy, dated 12/06/19, showed: -Portable lift should be used by two nursing assistants to perform procedure; -Assist resident in guiding his/her legs; -Always keep the resident centered over the base and facing the caregiver operating the lift; -The policy did not contain direction for position of the base legs during the transfer. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for four residents (Resident #6, #49, #68, and #69) at the time of meal service and failed to implement a system to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents who received room trays. The facility census was 117. Review of the facility's policy Nutrition, dated 9/10/23, showed the facility strives to enhance the health and quality of likes of all residents through nutritious and appetizing meals. 1. Observation on 10/31/24 at 8:44 A.M., showed facility staff delivered a hall tray to Resident #6's room. [...]
Inspectors wroteBased on interview and record review, facility staff failed to notify one resident (Resident #119) of one sampled resident's physician and representative in a timely manner when the resident had a fall with major injury. The facility census was 117. 1. Review of the facility's Notification of Family Members, Physician and Residents policy, dated 09/05/08, showed: -The purpose is to maintain communication and ensure that family members, physicians and residents are provided the opportunity to participate in the planning of medical care; -The resident's responsible party must be notified when there is a significant change of condition to include falls and injury; -The resident's physician and the facility administrator must be notified for significant changes of condition to include falls and injury; [...]
Inspectors wroteBased on record review and interview, facility staff failed to follow their Abuse & Neglect policy to investigate an allegation of misappropriation of property and failed to contact the local law enforcement within the required timeframe for one resident (Resident #1) out of one sampled residents. The facility census was 122. 1. Review of the facility's policy titled, Abuse and Neglect, revised 05/10/19, showed staff are directed to do the following: -All allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be thoroughly investigated. The facility will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; [...]
Inspectors wroteBased on interviews and record review, facility failed to report a missing electronic device for one resident (Resident #1) out of one sampled residents to the Department of Health and Senior Services (DHSS) within the required timeframe. This has the potential to affect all residents. The facility census was 122. 1. Review of the facility's policy titled, Abuse and Neglect, revised 05/10/19, showed staff are directed: [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to perform hand hygiene in a manner to prevent the spread of infection and failed to clean and sanitize soiled utensils between uses to prevent cross-contamination. Facility staff failed to maintain the kitchen floors and appliances in a clean manner to prevent the growth and harborage of bacteria. This had the potential to affect all residents. The facility census was 112. 1. Review showed the facility did not provide a policy for hand hygiene or glove changes. 2. Review of the facility's posting, Stop Germs! Wash You Hands, undated showed staff were directed to keep hands clean is one of the most important things we can do to stop the spread of germs and stay healthy. [...]
Inspectors wroteBased on interview and record review, facility staff failed to complete a thourough investigation when staff reported one resident (Resident #5's) jar of quarters missing from his/her room. Staff did not interview additional residents, witnesses and family members. The facility census was 113. 1. Review of the facility's Abuse and Neglect policy, revised 5/10/19, showed the policy designed to prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents, and misappropriation of resident property and to ensure appropriate intervention, investigation, and timely reporting in response to allegations of abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source, and misappropriation of resident property, staff were directed as follows: -Investigation and Protection: [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the resident environment remained free of accident hazards when staff failed to secure medications and sharps on unattended medication carts. The facility census was 117. 1. Review of the facility's policy titled, Medication Administration, dated 9/09/23, showed staff must secure medications at all times. When not in use, medication cart drawers should be locked. Medications shall not be left unattended on counters or work stations. 2. Observation on 12/06/23 at 10:26 A.M., showed an unattended medication cart. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. Facility staff failed to wear an N95 (respirator) mask during the provision of care for two COVID-19 positive residents (Resident #3, and #4). The facility census was 117. 1. Review of the facility's policy, Guideline For Isolation Precautions, dated 9/28/21, showed the policy did not instruct what type of mask staff should use for suspected or confirmed SARS-CoV-2 infections. [...]
Inspectors wroteBased on observation, record review, and interview, facility staff failed to provide a clean, safe, and comfortable homelike environment when staff failed to ensure one resident's (Resident #2) bed was in good repair. The facility census was 117. 1. Review of the facility's policy titled, Faulty Equipment, undated , showed staff shall alert their supervisor of faulty equipment. Supervisors should send an email to the Maintenance Department to report the issue. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/30/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Dependent on staff for bed mobility and transfers; [...]
Inspectors wroteBased on record review and interviews, facility staff failed to report an allegation of employee to resident verbal abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two hour required time frame. The facility census was 118. 1. Review of the facility's policy titled, Abuse and Neglect, revised May 2019, showed allegations of abuse, mistreatment, neglect, exploitation, and misappropriation of resident property will be appropriately investigated and timely reported per federal and state laws. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to assist two residents (Resident #3 and #4) with their meals. The facility census was 117. 1. Review of the facility's policy, Activity of Daily Living (ADL) Services, dated 10/01/21, showed staff shall provide residents assistance with ADL's every shift, as appropriate. ADL's include bathing, grooming, dressing, eating, oral hygiene, ambulation and toilet activities. Review of the facility's Menu Board located on Walnut Grove Hall, showed lunch will be served between 12:20 P.M., and 12:30 P.M. 2. Review of Resident #3's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/15/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Supervision from staff member with eating; [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain prepared foods at the proper temperature before service, failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to use the sanitizing solution according to facility policy and manufacturer's instructions and to allow clean and sanitized kitchenware to dry prior to use to prevent the growth of food-borne pathogens. Facility staff also failed to replace a missing ceiling tile in the food preparation area. The facility census was 111. 1. Review of the facility's policy titled, Food Temperatures policy, undated, showed hot foods on the tray line should be above 140 degrees F. If less than that, should be returned for reheating. The policy did not contain guidance specific to microwave reheating of meals. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to include in the plans oxygen use for two residents (Resident #3 and #55), Continuous Positive Airway Pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) use for two residents (Resident #48 and #417), and activity preferences for one resident (Resident #107). The facility census was 111. 1. Review of the policies provided by the facility showed no policy for Care Plans. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2019, showed staff are directed to: [...]
Inspectors wroteBased on observation, interview, and record review facility staff failed to assist four out of six sampled dependent residents (Resident #39, #67, #80 and #93) with grooming and bathing as needed. The facility census was 111. Review of the policies provided by the facility showed no policy for the care of dependent residents. 1. Review of Resident #39's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/1/23, showed facility staff assessed the resident as: -Severe Cognitive impairment; -Totally dependent on one staff member for transfers; -Required extensive assistance from two or more staff members for dressing; -Totally dependent on one staff member for bathing. Review of the resident's care plan, dated 1/25/23, showed staff were directed to assist the resident to the extent needed to remain dry, clean, and well groomed. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer three residents (Residents #46, #29 and #39) by sling-type mechanical lift and one resident (Resident #78) by Sit to Stand mechanical lift), in a manner to prevent accidents. Additionally, staff failed to properly secure one medication cart. The facility census was 111. 1. Review of the facility's policy titled, Use of Lift Machine, dated 12/6/19, showed staff are directed to do the following: -Portable lift should be used by two staff members to perform procedure; -Make sure the lift is stable, legs fully extended, and locked. The lifter's base must be spread to the widest position and the brakes activated and locked. 2. Review of the Resident #46's Annual Minimum Data Set (MDS), a federally mandated assessment tool, 05/02/23, showed staff assessed the resident as: [...]
Inspectors wroteBased on observation, interview, and record review facility staff failed to store and label medications in safe and effective manner in two of three medication storage rooms, and two of three medication storage carts. The facility census was 111. 1. Review of the facility's policy titled Storage/Labeling of Drugs, dated 12/2/2013, showed staff are directed to do the following: -All medications will be checked at least monthly for expiration dates; -Expired medications are to be destroyed through the use of drug buster. 2. Observation on 06/27/23 at 2:34 P.M., showed the Walnut hall medication storage room contained one box of Albulterol Sulfate 0.63 mg with an expiration date of May 2023. Observation on 06/27/23 at 3:00 P.M., showed the Cherry hall medication storage room contained one dressing change kit with an expiration date of May 2023. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during incontinence care for one resident (Resident #46) and wound care for one resident (Resident #42). Additionally, staff failed to decrease the risk of infection for four residents (Resident #55, #30, #3, and #79) when staff failed to ensure sanitary conditions for oxygen tubing, and failed to sanitize or clean a Continuous Positive Airway Pressure (CPAP), (a machine that used mild air pressure to keep breathing airways open while you sleep), machine and tubing for one resident (Resident #48). The facility census was 111. 1. Review of the facility's policy, Hand Hygiene, revised 10/30/2018, showed staff were directed to do the following: [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to notify one resident's (Resident #64) physician when staff identified the resident with Moisture Associated Skin Damage (MASD) and failed to obtain treatment orders. The facility census was 111. 1. Review of the facility's policy titled Skin Care Protocol, dated 07/01/2011, showed staff are directed to do the following: -To ensure prompt and appropriate treatment for skin conditions identified by clinical staff, the following protocol may be initiated and the physician notified; -Initiate skin protocol; -Notify the physician of house protocol and obtain orders; -Update care plan, Treatment Administration Record (TAR), Physician Order Sheet (POS) with any new interventions for skin breakdown. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain a physician's order for the use of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #3), and failed to document when they discontinued or changed the catheter. Facility census was 111. 1. Review of the facility's policy titled, Catheter Care, revised October, 2018, showed staff were directed to document in the clinical notes the replacement of or any changes in apparatus, size of catheter, size of balloon, amount of fluid in the balloon when inflated and the date/time. Review of the facility's policy titled, Physician Visits and Medical Orders, undated, showed staff were directed to do the following: [...]
32 fire safety citations on file: 5 on January 30, 2026, 9 on November 1, 2024, 18 on June 29, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| January 14, 2025 | Fine | $9,110 |
| January 14, 2025 | Fine | $9,110 |
| November 1, 2024 | Fine | $19,401 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Missouri | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.20 | 3.43 | 3.86 |
| Registered nurses | 0.59 | 0.46 | 0.69 |
| All nursing staff on weekends | 3.83 | 3.01 | 3.42 |
| Nurse aides | 3.02 | ||
| Licensed practical nurses | 0.59 | ||
| Nursing staff turnover (share who left in a year) | 61.8% | 56.0% | 45.8% |
| Registered nurse turnover | 56.5% | 47.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.73 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.34 on weekdays and 3.83 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.99 in April to June 2025 to 4.20 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.20 | 0.59 | 4.34 | 3.83 | 0.0% | 0 of 90 | 118 |
| Oct to Dec 2025 | 4.14 | 0.50 | 4.32 | 3.70 | 0.0% | 0 of 92 | 122 |
| Jul to Sep 2025 | 4.16 | 0.36 | 4.32 | 3.73 | 0.0% | 0 of 92 | 118 |
| Apr to Jun 2025 | 3.99 | 0.47 | 4.22 | 3.41 | 3.5% | 0 of 91 | 118 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Missouri, Jan to Mar 2026 | 3.34 | 0.40 | 3.50 | 2.93 | 3.9% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Missouri, all employers | |||
| CNAs (nursing assistants) | $18.11 | $17.02 to $20.00 | 34,050 |
| LPNs and LVNs | $29.58 | $27.06 to $33.77 | 14,700 |
| Registered nurses | $39.32 | $36.56 to $47.39 | 76,310 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Missouri | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 22.2 | 18.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 3.5 | 1.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.7 | 2.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.2 | 4.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 18.8 | 17.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.4 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.3 | 23.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 15.4 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 23.2 | 13.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.4 | 2.3 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Bluffs, the's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
55.6% this home
No different from the national rate
US median of homes 51.5% · Missouri: 41 better, 31 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 133 eligible stays.
11.1% this home
No different from the national rate
US median of homes 10.7% · Missouri: 0 better, 7 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 163 eligible stays.
8.9% this home
No different from the national rate
US median of homes 7.1% · Missouri: 1 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 82 eligible stays.
35.9% this home
Median of homes: Missouri51.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 53 residents counted.
1.4% this home
Median of homes: Missouri0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 69 residents counted.
0.0% this home
Median of homes: Missouri2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 69 residents counted.
71.0% this home
Median of homes: Missouri100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 31 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BOONE COUNTY SENIOR CITIZEN SERVICE CORPORATION.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Gershman Investment Corp. | 5% or greater mortgage interest | Organization | 10/24/2011 | |
| Dresner, Jessica | Corporate director | Individual | 06/30/2025 | |
| Moore, Christina | Corporate director | Individual | 05/01/2019 | |
| Moss, Janet | Corporate director | Individual | 12/31/2023 | |
| Prost, Evan | Corporate director | Individual | 04/30/2024 | |
| Simpson, Doris | Corporate director | Individual | 09/30/2024 | |
| Velloff-Burris, Tara | Corporate director | Individual | 05/31/2023 | |
| Bacon, Suzette | Corporate officer | Individual | 04/30/2023 | |
| Baker, Jennifer | Corporate officer | Individual | 06/30/2025 | |
| Fairchild, Julia | Corporate officer | Individual | 03/09/2021 | |
| Gilbert, Barry | Corporate officer | Individual | 03/31/2022 | |
| Minner, Donna | Corporate officer | Individual | 02/28/2023 | |
| Fairchild, Julia | Operational/managerial control | Individual | 03/09/2021 | |
| Moore, Christina | Operational/managerial control | Individual | 05/01/2019 | |
| Sjoblom, Beth | Operational/managerial control | Individual | 01/25/2024 | |
| Forvis Mazars LLP | Adp of the SNF | Organization | 03/17/2021 | |
| Kpm Cpas, PC | Adp of the SNF | Organization | 11/01/2023 | |
| Midwest Physical Therapy PC | Adp of the SNF | Organization | 10/01/2024 | |
| Fairchild, Julia | Adp of the SNF | Individual | 03/09/2021 | |
| Harrington, Ranshell | Adp of the SNF | Individual | 11/26/2024 | |
| Moore, Christina | Adp of the SNF | Individual | 05/01/2019 | |
| Prentice-Kuhn, Amy | Adp of the SNF | Individual | 06/01/2021 | |
| Sjoblom, Beth | Adp of the SNF | Individual | 01/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Missouri. NursingHomeClear cannot take or act on complaints.