Capitol River Wellness & Rehabilitation
1221 Southgate Lane, Jefferson City, MO 65110 · Cole County · 120 certified beds · avg 74 residents/day · certified since Mar 9, 1993
Part of chain: NORBERT BENNETT & DONALD DENZ (2 facilities, chain avg rating 1.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 29, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 23, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 21, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 21, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| May 21, 2026 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 21, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 28, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 4, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 4, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Dec 19, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Feb 8, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Feb 8, 2024 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 8, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 8, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 14, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 1 | J ▲ |
| 2024 | 14 | 0 | F |
| 2025 | 3 | 0 | D |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $14,446.
| Date | Type | Amount / length |
|---|---|---|
| Sep 29, 2023 | Fine | $14,446 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.21 | 3.66 | 3.95 | bottom 32% in Missouri; bottom 22% in the U.S. |
| Registered Nurse hours | 0.31 | 0.49 | 0.69 | bottom 29% in Missouri; bottom 11% in the U.S. |
| Weekend total nurse staffing | 2.79 | 3.22 | 3.50 | bottom 31% in Missouri; bottom 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.33 | 0.48 | bottom 24% in Missouri; bottom 10% in the U.S. |
| Total nursing staff turnover (%) | 64.5 | 56.0 | 45.8 | bottom 27% in Missouri; bottom 10% in the U.S. |
| RN turnover (%) | 33.3 | 47.8 | 42.9 | top 26% in Missouri; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.66, RN 0.36, weekend 3.19. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bennett, Norbert | Individual | 5% or Greater Indirect Ownership Interest | 32% | 10/04/2004 |
| D&N, LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 12/31/2004 |
| Denz, Donald | Individual | 5% or Greater Indirect Ownership Interest | 44% | 10/04/2004 |
| Donald T Denz Irrv Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 05/23/2008 |
| DTD HC LLC | Organization | 5% or Greater Direct Ownership Interest | 50% | 12/31/2004 |
| Norbert a Bennett Irrv Tr Fbo Children | Organization | 5% or Greater Indirect Ownership Interest | 12% | 05/23/2008 |
| Norbert a Bennett Irrv Tr Fbo Grandchildren | Organization | 5% or Greater Indirect Ownership Interest | 6% | 05/23/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Stonebridge Villa Marie | 0.5 mi | Jefferson City, MO | ★☆☆☆☆ | 3/5 | |
| Stonebridge Adams Street | 0.8 mi | Jefferson City, MO | ★★☆☆☆ | 2/5 | |
| Jefferson City Manor Care Center | 1.1 mi | Jefferson City, MO | ★☆☆☆☆ | 3/5 | |
| Heisinger Bluffs Rehab and Healthcare Center | 1.6 mi | Jefferson City, MO | ★★★★☆ | 4/5 | |
| Heisinger Bluffs Healthcare Western Campus | 1.6 mi | Jefferson City, MO | ★★★★★ | 5/5 | |
| River City Living Community | 3.0 mi | Jefferson City, MO | ★☆☆☆☆ | 1/5 | |
| Stonebridge Oak Tree | 3.1 mi | Jefferson City, MO | ★★★★☆ | 4/5 | |
| Stonebridge Westphalia | 13.5 mi | Westphalia, MO | ★★★☆☆ | 3/5 | |
| Riverview Nursing Center | 18.6 mi | Mokane, MO | ★★★★☆ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265530.