Home / Missouri / Jefferson City
1024 Adams Street, Jefferson City, MO 65101 · Cole County · (573) 635-1320
120 certified beds, about 49 residents a day · For profit - Corporation · Medicare and Medicaid since 2007
CMS Care Compare ratings, data as of September 1, 2026 · CCN 265810 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 4, 2024, inspectors cited 14 health deficiencies (the Missouri average is 11.4, the national average 9.2).
Of 40 health citations since June 2022, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $38,656 in the last three years; the largest was $38,656, and the latest is dated December 4, 2024.
Nurses and nurse aides worked 3.72 hours per resident per day, against 3.43 across Missouri and 3.86 nationally. Registered nurses accounted for 0.81 of those hours.
72.0% of nursing staff left within the year CMS measured (Missouri average 56.0%).
CMS links it to Stonebridge Senior Living, an affiliated group of 12 nursing homes.
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 40 health citations on file.
Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide safe mechanical transfer for one resident (Resident #1) and staff failed to transfer one resident (Resident #3) in a safe manner. Census was 47.1. Review of the facility's policy, Safe Lifting and Movement of Residents, dated 07/2017, showed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Review of the facility's policy, Hoyer Safety, undated, showed staff are directed to lock the wheels and widen the base to transfer. The policy did not provide direction for staff when to close the base of the lift. The facility did not provide a policy regarding safe transfers using a gait belt. 2. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate hand hygiene infection control practices during perineal care for one residents (Resident #1) out of two sampled residents, staff 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), failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when facility staff failed change and/or store oxygen in a manner to prevent the spread of bacteria. The facility census was 47.1. Review of the facility's policy, Oxygen Concentrator, dated 01/2018, showed nursing staff were responsible to change oxygen tubing and mas/cannula weekly and as needed if it becomes soiled or contaminated. [...]
Inspectors wroteBased on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. The facility census was 55. 1. Review of the facility's staffing policy, dated 10/2017, showed the facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care.2. Review of the Facility Assessment, dated 10/30/25, showed the assessment includes an evaluation of the resident population and available facility resources and services to ensure person centered care needs are completely met. [...]
Inspectors wroteBased on observation, interviews and record review, facility staff failed to ensure one resident (Resident #1) who received tube feeds (supplemental liquid nutrition) through a gastrostomy (G-tube) (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received his/her supplemental liquid nutrition as ordered by the physician. The census was 55.1. Review of the facility's Enteral Nutrition policy, undated, showed adequate nutritional support through enteral feeding will be provided to residents as ordered. The policy showed recommendation to initiate the use of a feeding will be based on the results of the comprehensive nutritional assessment, and will be consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure oxygen tubing and/or nebulizer mask and tubing were changed at least weekly for four residents (Resident #1, #2, #3, and #4) out of four sampled residents and failed to provide orders for oxygen therapy for one resident (Resident #4). The facility's census was 58. 1. Review of the facility's Oxygen Concentrator policy, revised 01/2018, showed: -Oxygen is administered under orders of the attending physician, except in the case of an emergency;-Keep delivery devices covered in plastic bag when not in use;-Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated;-Change humidifier bottle when empty, every 72 hours, or as recommended by the manufacturer;-If applicable, change nebulizer tubing and delivery devices every 72 hours. 2. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when facility staff failed to serve meals in a timely manner to residents and failed to maintain the internal temperatures of hot food to at least 120 degrees Fahrenheit ( F) upon service to residents who resided on the 300 and 400 halls. The facility census was 58.1. Review of the facility's Food Preparation and Service policy, dated July 2014, showed the danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. 2. [...]
Inspectors wroteBased on interview and record review, facility staff failed to check the Employee Disqualification List ((EDL) a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) and/or criminal background check (CBC), prior to hire in accordance with their facility policy for eight employee (Certified Nurse Aide (CNA) I, Licensed Practical Nurse (LPN) J, receptionist K, Social Services Director, Certified Medication Technician (CMT) L, housekeeper N, Nurse Aide (NA) B, and Food Service Manager) out of ten sampled employees. Facility staff failed to develop an abuse and neglect policy that directed staff to check the NA registry for all employees, prior to hire, for seven employees (CNA I, LPN J, Receptionist K, Social services director, CMT L, housekeeper N, and NA B) out of 10 employees. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to accurately assess the use of side rails for three residents (Resident #2, #49, and #52), and failed to complete an entrapment risk assessment for five residents (Resident #1, #2, #49, #52, and #106), out of 14 sampled residents. The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's Proper use of Side Rails Policy, dated 09/2022, showed: -Examples of bedrails include, but are not limited to side rails, bed side rails, safety rails, grab bars, and assist bars; -The resident assessment must assess the resident's risk from using bed rails such as entrapment; -The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself; [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week. The facility's census was 53. 1. Review of the facility's Nursing Services Registered Nurse Policy, dated October 2022, showed it is the intent of the facility to comply with RN staffing requirements, and the facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. 2. Review of the facility's time-keeping records for consecutive hours worked by an RN for August 2024, showed: -Saturday, 08/17/24: 7.55 hours; -Sunday, 08/18/24: 7.9 hours. Review of the facility's time-keeping records for consecutive hours worked by an RN for September 2024, showed: -Sunday, 09/01/24: 7.83 hours; -Saturday, 09/07/24: 7.6 hours; -Sunday, 09/08/24: seven hours; [...]
Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, when staff failed to follow recipes. The facility census was 53. 1. Review of the facility's Standardized Recipes policy, revised April 2007, showed staff were directed to use only tested, standardized recipes to prepare foods. Review showed standardized recipes will be adjusted to the number of portions required for a meal. Review of the facility's standardized recipe for 52 servings of shepherd's pie showed staff were directed to include 16 pounds of ground beef, one and one-eighth of a #10 (approximately seven pounds) can of tomatoes and one gallon plus one cup of potatoes. Review showed the recipe also included peas and carrots. [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to store ice scoops in a manner to prevent contamination and failed cover resident meals in a manner to prevent contamination. Facility staff failed to maintain the ice machine drain air gap. The census was 53. 1. Review of the facility's Food Receiving and Sorage policy, revised July 2014, showed: -Food in desiganted dry storage areas shall be kept off the floor at least 18 inches; -All foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date; -Other opened containers must be dated and sealed or covered during storage; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated. 2. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for six employees (Certified Nurse aide (CNA) I, Licensed practical nurse (LPN) J, Receptionist K, transporter M, Housekeeper N, and nurse aide (NA) B) out of ten sampled employees. [...]
Inspectors wroteBased on record review, and interview, facility staff failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet resident's needs for three residents (Resident #20, #49, and #56) out of 14 sampled residents. The facility census was 53. 1. Review of the facility's Comprehensive Care Plans policy, September 2022, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to safely transfer two residents (Resident #14 and #52) of two sampled residents via mechanical lift, in a manner to prevent accidents. The facility's census was 53. 1. Review of the facility's policy titled, Using a Mechanical Lift Machine, dated July 2017, showed staff were directed as follows: -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Staff must be trained and demonstrate competency using the specific machines or devices used in the facility; -Gently support the resident as he or she is moved, but do not support any weight; -The policy did not contain direction for position of the base legs during the transfer. 2. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 27 opportunities observed, seven errors occurred, resulting in a 25.93% error rate, which affected two residents (Resident #16, and #36). The facility census was 53. 1. Review of the Facility's Administering Medications policy, dated 12/2012, showed: -Medications must be administered in accordance with the orders including any required time frame; -Individual administering the medication must check to verify right time; -The Expiration/beyond use date on the medication label must be checked prior to administering, when opening a multi-dose container, the date opened shall be recorded on the container; Review of the Facility's Medication Errors policy, dated 04/2017, showed: [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner when staff failed to properly label, and/or discard expired insulin medications from two of two sampled medication carts. The facility census was 53. 1. Review of the facility's policy titled, Administering Medications, dated 12/2012, showed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 2. Observation on [DATE] at 9:26 A.M., showed the 100/200 hall medication cart contained two Lantus insulin Pens opened and undated. During an interview on [DATE] at 9:30 A.M., Certified Medication Technician (CMT) P said insulin pens are usually only good for 28 days. [...]
Inspectors wroteBased on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate) for four residents (Resident #25, #34, #38, and #54) out of four sampled resident who transfered to the hospital. The facility's census was 53. 1. Review of the facility policies showed the facility did not have a policy for Ombudsman notification. 2. Review of Resident #25's medical record showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 3. Review of Resident #34's medical record showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #25, #34, #38, and #54) out of 14 sampled residents. The facility's census was 53. 1. Review of the facility's Bed Holds policy, dated March 2022, showed the facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed-hold policy. 2. Review of Resident #25's medical record showed the resident discharged from the facility on 10/15/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information on a daily basis, which included the facility name, current date, resident census, total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift. Facility staff failed to keep the required daily staffing records for 18 months. The facility's census was 53. 1. Review of the facility's policy titled, Nurse Staffing Posting, dated September 2022, showed: -The facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; -It is the policy of the facility to make nurse staffing information readily available in a readable format to resident and visitors at any given time; [...]
Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 53. 1. Review of the facility Food Services Manager policy, updated 9/28/22, showed the director of food and nutrition services must at a minimum meet one of the following qualifications: -A certified dietary manger (CDM); -A certified food service manager; -Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management. [...]
Inspectors wroteBased on interview and record review, facility staff failed to contact one resident's (Resident #3) responsible party and physician when the resident had an unwitnessed fall. The facility census 54. 1. Review of the facility's Change in a Resident's Condition or Status Policy, dated 5/2017, showed staff are directed to promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Unless otherwise instructed by the resident a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 2. [...]
Inspectors wroteBased on interview and record review, facility staff failed to complete neurological checks for three residents (Resident #1, #2, and #3) out of three sampled residents who had unwitnessed falls. The facility census was 54. 1. Review of the facility's Fall Clinical Protocol Policy, dated 09/2012, showed falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such a sliding out of a chair or rolling from a low bed to the floor. Review of the facility's Post Fall Step by Step Policy, undated, showed staff are to complete post fall initial clinical assessment completed one time directly after each fall. [...]
Inspectors wroteBased on interview and record review, facility staff failed to complete neurological checks and fall follow up documentation for three residents (Resident #1, Resident #2, and Resident #3) of three sampled residents who had un-witnessed falls. The facility census was 55. 1. Review of the facility's Post Fall step by step Protocol, undated, showed first post fall initial clinical assessment is completed one time directly after each fall. Review showed post fall 72 hour monitoring, with a head injury complete assessment is completed according to neurological timelines. 2. Review of Resident # 1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/20/24, showed staff assessed the resident as: -Cognitive impairment; -Dependent for mobility; -Resident at risk for falls with two falls since admission or prior assessment. [...]
Inspectors wroteBased on interview and record review, facility staff failed to provide a proper transfer for one resident (Resident #1) in a manner to prevent accidents, when staff did not utilize two staff as directed and the resident sustained an injury to his/her leg. The facility census was 56. 1. Review of the facility's Safe Lifting and Movement of Residents Policy, revised July 2017, showed: -In order to protect the safety and the well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to life and move residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 2. [...]
Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff also failed to wear hair restraints to protect food and food contact surfaces from potential contamination. The facility census was 53. 1. Review of the Food Safety Requirements policy, dated September 2022, showed the policy directed staff to label and date opened food items and to store foods covered or in air tight containers. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to update the resident's care plan for one resident (Residents #7) who used oxygen, and for one resident (Resident #19) whose advanced directive changed from a full code to a Do Not Resuscitate (DNR). The facility census was 53. 1. Review of the facility's Care Planning - Interdisciplinary (IDT) team policy dated September 2013, showed: -The facility's care planning/IDT members are responsible for the development of an individualized comprehensive care plan for each resident; -The resident's care plan is based on the comprehensive assessment. Review of the facility's Comprehensive Care plan policy dated September 2022, showed: -The comprehensive care plan will describe, at a minimum, the following: a. [...]
Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain professional standards of documentation when staff failed to obtain a physician order for the use of assistive devices for four residents (Resident #7, #12, #30, and #37), failed to complete bed rail assessments to show the use of the assistive devices for three residents (Resident #30, #37, and #51) as directed in the facility policy, failed document one resident's skin weekly as ordered (Resident #53), and failed to consult with the physician on a dietary recommendation for a supplement on one resident (Resident #53). The facility census was 53. 1. Review of the facility's Proper Use of Side Rails Policy, dated September 2022, showed: [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to to clean and store respiratory equipment and devices in a manner to prevent the spread of infection for nine residents (Residents #7, #10, #14, #17, #26, #34, #36, #46, and #51). The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for oxygen use, cleaning, and/or storage. Review of the facility's Infection Prevention and Control Manual General Policies Cleaning and Disinfecting Nebulizer Equipment, dated 2017, showed staff were directed to do the following: -Apply gloves; -Disassemble the nebulizer by removing the cup and mask or mouthpiece; -Thoroughly clean all visible soil or organic material from the cup, mask, or mouthpiece before disinfection; -Use warm water and mild dish detergent to was the nebulizer parts or follow manufacturers recommendations; [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medications and biologicals in a safe effective manner for one of two medication carts, one treatment cart, one of two medication storage rooms, one crash cart, and two resident's (Resident #12 and #37) rooms. The facility census was 53. 1. Review of the facility's policy titled, Storage of Medications, revised April 2007, showed staff were directed to do the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed; [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents were treated in a manner to maintain their dignity when staff failed to announce themselves and wait for permission before entering the room for one resident (Resident #34), hung visible care signs for one resident (Resident #21) fluid consistency, and failed to provide privacy by ensuring the door was closed during a medication injection and blood glucose test for one residents (Resident #20). The facility census was 53. 1. Review of the facility's Nursing Home Residents' Rights pamphlet and Resident and Family Handbook, undated, showed the residents have a right to a dignified existence and be treated with consideration, respect, and dignity, recognizing each residents individuality and to privacy during treatment and care of personal needs. [...]
Inspectors wroteBased on record review and interview, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 53. 1. Review of the facility's Infection Preventionist policy, dated September 2022, showed the facility will designate a qualified individual as IP whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program. The facility will ensure the IP is qualified by education, training, experience or certification. During the entrance conference on 11/14/23 at 9:43 A.M., the Administrator said they do not currently have a certified IP person. [...]
Inspectors wroteBased on interview and record review, facility staff failed to maintain a surety bond sufficient to ensure protection of resident funds for 18 of 18 sampled residents. The facility held funds for a total of 18 residents. The facility census was 53. 1. Review of the facility's Resident Trust Fund Account Policy and Procedure, dated 11/28/16, showed the facility has a current surety bond in the amount equal to at least one and one-half times the average total of the monthly balances and will be reviewed annually. Review of the facility's resident fund account bank statements from May 2021 through April 2022, showed an average monthly balance of $29,324, which would require a bond of $43,986. Review of the Department of Health and Senior Services (DHSS) approved bond list, dated 4/17/18, showed the facility had a bond for $30,000. [...]
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 residents medical, and nursing needs when they failed to address the code status for two residents (Resident #30 and #203), failed to address falls for one resident (Resident #21) and failed to address oxygen use for one resident (Resident #38). The facility census was 53. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated [DATE], showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to revise the care plan for two residents (Resident #26 and Resident #29) who had a change in code status, and one resident (Resident #35) who received an anticoagulant (medication used to thin the blood to reduce the risk of blood clots). Additionally, staff failed to follow the care plan for two residents (Resident #26 and Resident #43) one of which was at risk for falls and required the use of fall mats. The facility census was 53. 1. Review of the facility's Comprehensive care plan policy, dated [DATE], showed: -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes; [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care consistent with professional standards of practice when they failed to document assessments, and contact the physician for two residents (Residents #27 and #210) who sustained falls at the facility, failed to obtain a physician's order for one residents (Resident #21) code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) and one residents (Resident #38) oxygen. Additionally, staff failed to clean and maintain oxygen concentrator filters for one resident (Resident #44) who was dependant on oxygen. The facility census was 53. 1. Review of the facility's Clinical Protocol for Falls, dated [DATE], directed staff: -Staff will evaluate and document falls that occur while the individual is in the facility; [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain a physician's order for an indwelling urinary catheter (tube inserted into the bladder to drain urine) and an indication for the use of the catheter for one resident (Resident #21). Additionally, staff failed to obtain orders for catheter care, and catheter/balloon size for two residents (Resident #21 and #203), one of which had a Urinary Tract Infection (UTI). The facility census was 53. 1. Review of the facility's Physician Services policy, dated April 2013, showed it did not contain direction for staff in regards to catheter orders or care of catheters. Review of the facility's Catheter Care, Urinary policy, dated September 2014, showed the purpose of the procedure is to prevent catheter-associated urinary tract infections (CAUTI) and directed staff to document: [...]
Inspectors wroteBased on observation, interview and record review, facility staff failed to complete ongoing assessments to assure bed rails were used to meet the resident's needs, for three residents (Resident #7, #10, and #50). The facility census was 53. 1. Review of the facility's Proper Use of Side Rails Policy, dated October 2017, showed: -The facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need and determination when the side rail/bed rail will be discontinued; -The use of side rails/bed rails as an assistive device will be addressed in the residents' care plan and Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. 2. Review of Resident 7's Quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; [...]
Inspectors wroteBased on observation and interviews, the facility staff failed to store food in a manner to prevent cross-contamination and out-dated use. The facility census was 53. 1. Review of the facility's Food Receiving and Storage policy, dated 2001, showed: -Foods shall be received and sstored in a manner that complies with safe food handling practices; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system; -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -Uncooked and raw animal products and fish will be stored separately in drip-prood containers and below fruits, vegetables and other ready-to-eat foods. Observation on 05/31/22 at 9:18 A.M., showed six clear containers on a three-tier cart with dry cereal, not labeled or dated. [...]
Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure one resident (Resident #11) had an appropriate indication and diagnoses for the use of an anitpsychotic medication (medication that alters brain activity) and failed to contact the physician with pharmacy recommendations for Gradual Dose Reductions (GDRs) (a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for psychoactive medications for two residents (#32 and #38). The facility census was 53. 1. Review of the facility's Medication Regimen Review (MRR) policy, dated 10/17, showed: -A review of psychotropic drug use will occur with every MRR. A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. [...]
Inspectors wroteBased on interview and record review, facility staff failed to inform residents of their rights during their stay in the facility. The facility census was 53. 1. During a group interview on 05/31/22 at 1:15 P.M., residents #2, #7, #8, #15, #20, #30, # 46, #48 and #49 said the following: - They did not know where the resident rights were posted in the facility; - The staff did not review their rights with them. Review of Resident Council Meeting notes, dated 3/2/22, 4/6/22, and 5/4/22, showed it did not contain documentation staff reviewed the resident's rights with the residents. During an interview on 6/3/22 at 3:00 P.M., Certified Nurse Aide (CNA) F said he/she does not know where the resident's rights are posted. He/She said he/she did not know who was responsible for posting the resident's rights. [...]
25 fire safety citations on file: 9 on December 4, 2024, 8 on November 17, 2023, 1 on September 28, 2023, 7 on June 3, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| December 4, 2024 | Fine | $38,656 |
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) | 3.72 | 3.43 | 3.86 |
| Registered nurses | 0.81 | 0.46 | 0.69 |
| All nursing staff on weekends | 2.85 | 3.01 | 3.42 |
| Nurse aides | 2.16 | ||
| Licensed practical nurses | 0.74 | ||
| Nursing staff turnover (share who left in a year) | 72.0% | 56.0% | 45.8% |
| Registered nurse turnover | 75.0% | 47.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.52 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 4.06 on weekdays and 2.85 on weekends, 30% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 15.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.00 in April to June 2025 to 3.72 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 | 3.72 | 0.81 | 4.06 | 2.85 | 15.5% | 0 of 90 | 49 |
| Oct to Dec 2025 | 3.64 | 0.62 | 3.95 | 2.86 | 10.4% | 0 of 92 | 53 |
| Jul to Sep 2025 | 3.39 | 0.46 | 3.65 | 2.74 | 5.7% | 0 of 92 | 54 |
| Apr to Jun 2025 | 4.00 | 0.48 | 4.33 | 3.16 | 25.3% | 0 of 91 | 49 |
| 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 | 6.2 | 18.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 7.9 | 4.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.0 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.0 | 17.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.7 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.0 | 23.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 33.2 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 5.5 | 13.7 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Stonebridge Adams Street's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 15 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 21 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 11 eligible stays.
20.0% 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. 20 residents counted.
3.5% 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. 29 residents counted.
4.9% 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. 29 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 1 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: ELDERCARE OF MID-MISSOURI X INC. CMS links this home to Stonebridge Senior Living, a group of 12 nursing homes averaging 3.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Lierman, Mark | 5% or greater direct ownership interest | Individual | 100% | 11/01/2021 |
| Lierman, Mark | Corporate officer | Individual | 11/01/2021 | |
| Miller, Beth | Corporate officer | Individual | 01/17/2023 | |
| Bridge Rehabilitation Inc | Operational/managerial control | Organization | 02/01/2024 | |
| Eldercare Management Services Inc | Operational/managerial control | Organization | 08/17/2010 | |
| Enterprise Bank & Trust | Operational/managerial control | Organization | 05/30/2008 | |
| Ciegel, Steven | Operational/managerial control | Individual | 04/01/2022 | |
| Doerhoff, Eric | Operational/managerial control | Individual | 11/01/2021 | |
| Knight, Kara | Operational/managerial control | Individual | 03/01/2018 | |
| Lierman, Mark | Operational/managerial control | Individual | 11/01/2021 | |
| Thayer, Jeanne | Operational/managerial control | Individual | 11/01/2021 | |
| Warbritton, Dustin | Operational/managerial control | Individual | 01/01/2011 | |
| White, Keri | Operational/managerial control | Individual | 08/19/2023 | |
| Bridge Rehabilitation Inc | Adp of the SNF | Organization | 04/22/2025 | |
| Eldercare Management Services Inc | Adp of the SNF | Organization | 04/22/2025 | |
| Forvis Mazars LLP | Adp of the SNF | Organization | 01/25/2016 | |
| Lierman Family Co X, LLC | Adp of the SNF | Organization | 01/01/2011 | |
| Wipfli LLP | Adp of the SNF | Organization | 01/01/2025 | |
| Ciegel, Steven | Adp of the SNF | Individual | 04/01/2022 | |
| Doerhoff, Eric | Adp of the SNF | Individual | 11/01/2021 | |
| Knight, Kara | Adp of the SNF | Individual | 03/01/2018 | |
| Lierman, Mark | Adp of the SNF | Individual | 11/01/2021 | |
| Thayer, Jeanne | Adp of the SNF | Individual | 11/01/2021 | |
| Warbritton, Dustin | Adp of the SNF | Individual | 01/01/2011 | |
| White, Keri | Adp of the SNF | Individual | 08/19/2023 |
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.