Westwood Hills Health & Rehabilitation Center
3100 Warrior Lane, Poplar Bluff, MO 63901 · For profit - Limited Liability company · 132 certified beds · (573) 785-0851 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.1% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.7% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 39.5% | 18.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 4.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.9% | 17.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 30.4% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 17.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.4% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 63.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.4% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.3% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.35 | 2.11 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.85 | 2.33 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 132 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.1%CMS range 47.2–62.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.1–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.9–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 132 beds and averages 79.2 residents a day — about 60% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.76 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.50 hrs/resident/day on weekends vs 2.87 on weekdays — 13% thinner on weekends. RN hours go from 0.64 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · D2025-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents (Residents #67 and #87) out of 18 sampled residents. The facility census was 74.Review of the facility's policy titled, Care Plan Review, undated, showed:- To ensure each resident will have an updated person-centered comprehensive care plan developed and implemented to meet and address the resident's medical, physical, mental and psychological needs;- Care plans are reviewed quarterly and as resident's condition changes;- Individualized to provide person-centered care;- Areas of review to provide but not limited to: activities of daily living (ADLs), nutrition, skin, behaviors, and individualized preferences. 1. Review of Resident #67's medical record showed:- admitted on [DATE];- Diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure one resident (Resident #48) out of 18 sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The facility's census was 74.Review of the facility's policy titled, Pain Prevention and Treatment, dated October 2017, showed:- Every resident will be assessed for pain using the Pain Screen including an appropriate pain rating scale upon admission and at least quarterly;- Residents who are not able to communicate verbally or have cognitive deficit that precludes them from answering yes/no questions will be screened using the pain observation screen;- Interventions for pain consist of pharmacological (related to drugs and how they relate to the body) and non-pharmacological (without drugs or medicine).1. Review of Resident #48's medical record showed:- An admission date of 11/21/25;- Diagnoses of urinary tract infection (UTI - an infection in any part of the urinary system), severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #3 and #36) had medications and biologicals labeled in accordance with currently accepted practices for two medication carts out of two sampled medication carts. This had the potential to affect all residents. The facility's census was 74.Review of the facility's policy titled, Medication Storage, dated October 2017, showed:- All medications must be clearly labeled with the resident name, drug name, strength, dosage, directions, and expiration date;- Any multi-dose vials or solutions, once opened, must be dated and initialed and discarded within 28 days unless manufacturer specifies otherwise.1.Observation of the A Hall medication cart on 12/05/25 at 7:40 A.M., for Resident #3 showed: - One opened bottle of Rybelus (diabetes medication) not labeled; - One opened bottle of prednisolone (eye drops-to treat inflammation of the eye) not labeled;- One opened bottle of fluticasone propionate (a nasal spray-to treat inflammation) not labeled;- One card with five tablets of Bactrim (an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow infection control protocols during wound care for one resident (Resident #81) out of five sampled residents. The facility census was 74.Review of the facility's policy titled, Dressings, Dry/Clean, dated January 2018, showed:- Put on clean gloves;- Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage;- Cleanse the wound. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward);- Use dry gauze to pat the wound dry;- Apply the ordered dressing and secure with tape;- Discard disposable items into the designated container;- Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.1. Review of Resident #81's medical record showed: - Diagnoses of cerebral infarction (stroke), vascular dementia (cognitive decline caused by reduced blood flow to the brain), dysphagia (difficulty swallowing), and anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 73. Review of the facility's policy titled, Cleaning and Sanitation - General, revised January 2012, showed: - The kitchen will be maintained in a clean and sanitary condition; the state and/or federal food code will be maintained on file within the food service department and will be the basis of all sanitation and food safety practices; - Hairnets or hair coverings will be worn at all times; - Utensils and dishes will be handled so that food and customer contact surfaces are not touched; Disposables will be opened from the bottom of the package; - Work surfaces will be kept neat and clean during food preparation and service. The department philosophy is Clean as you go. Review of the facility's policy titled, Cleaning Schedule, revised February 2012, showed: - There will be a written, comprehensive cleaning schedule…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the the resident's responsible party for three residents (Resident #32, #37 and #60) out of four sampled residents. The facility census was 73. Review of the facility's policy titled, Notice of a Transfer and/or Discharge, revised on October 2017, showed: - The facility shall provide a resident and/or the resident's representative with a 30-day written notice of an impending transfer or discharge; - Except as specified below, a resident, and/or his/her representative will be given notice as soon as practicable before transfer or discharge when: the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; the health of the individuals in the facility would otherwise be endangered; and an immediate transfer or discharge is required by the resident's urgent medical needs; - The written notice to the resident and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to the resident and/or their representatives at the time of transfer for three residents (Resident #32, #37 and #60) out of four sampled residents. The facility census was 73. Review of the facility's policy titled, Bed-Hold Policy, undated, did not address the facility providing the resident or resident's representative a written copy. 1. Review of Resident #32's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned on 05/03/24; - The resident transferred to the hospital on [DATE], and returned on 07/28/24; - No documentation of the written notification for the bed-hold policy provided to the resident and/or the responsible party on 04/30/24, and 07/28/24. 2. Review of Resident 37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and remained in the hospital; - No documentation of the written…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide needed care and services in accordance with professional standards of practice for one resident (Resident #12) out two sampled residents who required treatment due to a skin condition. The facility census was 73. The facility did not provide a policy related to treatment of skin conditions. 1. Review of Resident #12's Physician Order Sheet (POS), dated August 2024, showed: - admitted on [DATE]; - Diagnoses of psoriasis (a condition in which the skin cells build up and form scales and itchy dry patches), stroke, and aphasia (a language disorder that affects a person's ability to communicate); - An order for skin observations once a week every Saturday, dated 04/23/24; - No order for a psoriasis treatment. Review of the resident's care plan, last reviewed on 06/13/24, showed: - The resident has dry flaky skin and flare ups of psoriasis, at times has self-inflicted scratches on the face and head: - Resident will have ongoing evaluations and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment when the facility failed to monitor the elopement prevention wander guard system for one resident (Resident #70) out of one sampled resident and one resident (Resident #62) outside the sample. The facility census was 73. Review of the facility's policy titled, Elopement Prevention Policy, undated, showed: - The policy is to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement; - At the time of the screening and/or upon admission, ask the resident, resident representative, family members, referring source and past care givers if the resident has a history of wandering or elopement; - A licensed nurse will complete the Elopement Risk Assessment upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician's order for a catheter (a tube inserted into the bladder to drain urine) which included catheter care for two residents (Resident #10 and #28), failed to ensure a urinary catheter drainage bag was kept off the floor, and failed to ensure proper positioning of the catheter for one resident (Resident #10) out of two sampled residents. The facility census was 73. Review of the facility policy titled, Urinary Catheter Care, revised July 2017, showed; - The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; - Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled, Physician's Orders, dated February 2020, showed: - To complete documentation of an order; clarify the order, transcribe to Medication Administration Record (MAR) or Treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · D2024-08-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was obtained for two resident (Resident #10 and #43) out of two sampled residents. The facility census was 73. Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed staff to verify there is a physician's order and to review the order. 1. Review of Resident #10's medical record showed a diagnosis of heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment to be completed by facility staff), dated 03/25/24, showed the resident didn't receive oxygen. Review of the resident's August 2024 Physician Order Sheet (POS) showed no order for oxygen therapy or to change tubing. Review of the resident's Nurse's Notes, dated 08/16/24 showed: - The resident's vital signs: blood pressure-125/54, heart rate-94, respirations-34,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 48 opportunities with 24 errors made, for an error rate of 50% for three residents (Resident #43, #48 and #179) outside the seven sampled residents. The facility census was 73. Review of the facility's policy titled, Preparation and Administration, Oral Medication, undated, showed staff to remain with the resident until the medication is swallowed. Review of the facility's policy titled, Preparation and Administration, Nasal Medication, undated, showed administer the dosage, insert spray nozzle gently into the nose and spray. 1. Review of Resident #43's Physician Order Sheet (POS), dated August 2024, showed an order for Spiriva with HandiHaler (an inhaled bronchodialator medication) 18 microgram (mcg) 1 inhalation once daily, dated 04/13/21. Review of the resident's medical record showed; - No education and no assessment/competency completed for the resident to self-administer the Spiriva; - Care Plan, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended, leaving the narcotics behind only one lock. This had the potential to affect all residents The facility census was 73. The facility did not provide a policy regarding storage of medication. 1. Observation on 08/19/24 at 9:37 A.M., of the 60 Hall medication cart showed: - At 9:37 A.M., the medication cart was unlocked and faced the hall between the mechanical and the soiled utility rooms. Certified Medication Technician (CMT) F walked past the unlocked medication cart and placed a nystatin (an antifungal medication) bottle on top of the medication cart and walked down the hall; - At 9:41 A.M., a resident propelled him/herself in a wheelchair down the hall past the unlocked and unattended medication cart with the nystatin bottle on top of the medication cart; - At 9:44 A.M., CMT F walked to the medication cart, placed the nystatin bottle in the medication cart, and locked it; - At 11:05 A.M., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain proper infection control practices during incontinent care for four residents (Residents #4, #10, #38, and #50) out of four sampled residents and one resident (Resident #34) outside the sample, during wound care for two residents (Residents #50, and #57) out of three sampled residents, and during the medication pass for two residents (Residents #48 and #69) out of four sampled residents. The facility failed to disinfect the glucometer (a machine used to test how much sugar is in a blood sample) for three residents (Residents #24, #45, and #46) out of three sampled residents. The facility also failed to follow enhanced barrier precautions (EBP) for two residents (Residents #10 and #50) out of three sampled residents during care. The facility census was 73. Review of the facility's policy titled, Handwashing, revised April 2015, showed: - All staff thoroughly cleanses hands with friction, soap, and water to control infection and reduce transmission of organisms; - Hands should be thoroughly washed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 56. Record review of the facility's Cleaning and Sanitizing policy, not dated, showed: - Cleaning a surface, equipment or utensils involves the use of hot water and detergent. It removes soil, grease, food, and odors. It is a very important procedure for food handling; - All surfaces must be cleaned on a routine basis as well as whenever necessary even if not scheduled. Sometimes thorough cleaning involves the use of elbow grease or hard scrubbing because food is cooked on a utensil, the stain or food was not cleaned immediately, or because the job is not carried out often enough to ensure that the equipment or utensil remains clean; - Supplies, which may be useful for cleaning besides a detergent are: a heavy duty degreaser, brushes, stainless steel sponges, and steam cleaning equipment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 56. Observations on 3/7/23 at 11:11 A.M., 3/8/23 at 8:31 A.M., and 3/9/23 at 11:21 A.M., of the B hall showed: - room [ROOM NUMBER] with two - one inch (in.) x 18 in. areas, a two in. x eight in. area, and a two in. x two in. area with exposed sheetrock located behind the headboard of the bed by the window; - room [ROOM NUMBER] with several scratched up areas on the left lower side of the wall beside the nightstand by the window; - room [ROOM NUMBER] with a one in. x 12 in. area, a one in. x 8 in. area, and a 1 in. x 5 in. area with exposed sheetrock located behind the headboard of the bed by the window; - room [ROOM NUMBER] with a 21 in. x 40 in. area with the sheetrock cut out and unfinished on the left side wall of the bed by the window located behind the nightstand.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-03-10 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide information on the location of the Resident Rights, State Long-Term Care Ombudsman program (a statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights were preserved and respected). This practice could potentially affect all residents. The census was 56. Record review of the facility's Resident Rights policy, revised October 2017, showed: - The facility must post in a form and manner accessible and understandable to residents and resident representatives; - A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based services programs, and the Medicaid Fraud control Unit.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-03-10 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to notify residents of the availability and location of the most recent survey results in an accessible location to the residents. This practice had the potential to affect all residents and visitors. The facility's census was 56. Record review of the facility's Resident Rights policy, dated October 2017, showed: - The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; -The facility must post in a place readily accessible to the residents, and the family members and the legal representatives of the residents, the results of the most recent survey of the facility; - Post notices of the availability of such reports in areas of the facility that are prominent and accessible to the public. During a group meeting on 3/8/23 at 2:00 P.M., four residents (Resident #12, #16, #19, and #50) said they were not aware of the survey results availability. Observation on 3/8/23 at 3:50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-03-10 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 56. Observations from 3/7/23 through 3/9/23, showed the required daily nurse staffing information not found near any of the nurse's stations or the main lobby where it would be easily visible to residents and visitors. Observation on 3/10/23 at 8:51 A.M., showed the daily nurse staffing information posted in a dark purple colored notebook sleeve located in a frame on the wall in a recessed cove near a water fountain not in use. The staffing sheet was above eye level of a person in a standing position, approximately five feet above the floor level, and would have to be removed from the dark colored sleeve to know what it was. During an interview on 3/10/23 at 10:00 A.M., Licensed Practical Nurse (LPN) D said the scheduler…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HELIA HEALTHCARE — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 1 of 5 | 1.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 2.7 | +1.3 vs chain |
The other 12 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MILLER, STEPHEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | 100% | since 11/19/2014 |
| MARTIN, JOETTA | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2015 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $302K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265193. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.