Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quaker Hill Manor during CMS and state inspections, most recent first.
Kitchen Sanitation Deficiencies: Surveyors observed multiple sanitation issues in the kitchen, including dust and debris on the ice machine vent, food debris on a cart with clean trays, sticky and dusty residue on cereal and supply container lids, dried-on food on freezer doors and handles, and a blender base with thick dried-on food. Dietary staff confirmed the concerns, and the kitchen cleaning schedule called for daily cleaning of counters and carts and weekly cleaning of the ice machine, refrigerators, and freezers.
Failure to Maintain Resident Dignity During Personal Exposure: A resident with a hx of stroke, intact cognition, and dependence on staff for lower body dressing was observed sitting in her room with her door open and her gown and blanket pulled up to her waist, exposing her legs and upper thighs to the hallway. The resident stated she was unable to cover her legs with the blanket in her lap, while a CNA said she sometimes left her legs uncovered and an RN stated staff were expected to ensure residents were covered appropriately to protect dignity.
Failure to Provide Written Transfer Notifications: The facility failed to provide written notice to two residents and/or their representatives explaining the purpose or reason for hospital transfers. One resident had Parkinson's disease and intact cognition, and the other had lung cancer, respiratory failure, COPD, and CHF; both were transferred to the hospital, but their EMRs lacked documentation of the required written notifications. Staff interviews showed awareness gaps regarding the written notice requirement and ombudsman notification.
Failure to update a resident’s care plan for cancer and cancerous lesions. The resident had lung cancer, metastatic squamous cell carcinoma, and a bleeding cancerous thigh wound requiring daily dressing changes and oncology treatment, but the care plan only addressed skin breakdown risk and routine skin monitoring. Staff acknowledged the wound and cancer should have been documented in the care plan but were not.
Failure to Provide Oral Care to a Resident Dependent on Staff: A resident with a hx of stroke and intact cognition was documented as needing staff assistance with oral hygiene, but observations showed dried-on food debris around her mouth and a dry toothbrush and sink. The resident said she could not brush her teeth on her own and staff did not help her, while a CNA said she did not offer oral care during morning cares even though the resident was dependent on staff for oral hygiene.
Failure to monitor skin tears and manage constipation: A resident with CVA and dependent transfers developed skin tears during transfers, but wound documentation was incomplete and lacked ongoing assessment. Another resident with Alzheimer's disease went eight consecutive days without a bowel movement or constipation treatment despite a PRN enema order and a care plan requiring bowel monitoring and assessment after 72 hours without a BM.
A resident with severe cognitive impairment and a fall risk had his call light left on the floor during repeated observations, even though staff said it should always be within reach. Another resident with TBI and epilepsy was pushed in a wheelchair without foot pedals, despite being dependent on staff for wheelchair mobility and facility guidance stating leg rests must be attached whenever staff propel a resident.
A resident with HTN and intact cognition received metoprolol despite SBP readings below the ordered hold parameter of 110. The MAR showed the medication was administered on multiple occasions when SBP was out of range, and a CMA confirmed the doses were given outside the ordered parameters. An admin nurse stated staff were expected to hold medications when SBP was out of parameters.
Inadequate hand hygiene was observed during a resident’s peri care and transfer when a CMA and an LN wore the same soiled gloves while handling trash, obtaining supplies, wiping the peri area, and applying cream. The LN later changed gloves without hand hygiene and continued care of the resident’s catheter area and urethral opening. The LN confirmed the missed hand hygiene, and the DON stated staff were expected to perform hand hygiene after glove removal and between dirty and clean tasks.
The facility failed to post complete nurse staffing information for the census of 47 residents because the daily staffing sheets did not include the actual hours worked by nursing staff. Review of the staffing sheets showed the required hours were left blank, and an Administrative Nurse confirmed the omission. The facility policy stated the nurse staffing sheet must be posted daily and include the total number and actual hours worked by nursing staff.
Unsafe and Poorly Maintained Environment: The facility failed to maintain a safe, clean, and homelike environment in resident, visitor, and staff areas. Surveyors observed multiple damaged, cracked, broken, and stained ceiling tiles and hanging ceiling tracks in hallways, common areas, and outside resident rooms, along with cracks above several resident door frames. In the kitchen, food debris had built up around the perimeter of the floor, and dietary staff confirmed the floor was in poor condition and needed replacement.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions in one kitchen for a census of 47 residents. During an initial tour of the resident kitchenette, surveyors observed a vent on the front of the ice machine with a build-up of dust and debris, a cart holding clean plastic trays with food debris, eight plastic containers of cold cereal with a sticky, dusty substance on the lids, two large rolling plastic containers holding sugar and potatoes with a sticky, dusty substance on the lids, four reach-in freezer doors with dried-on food, freezer handles with food debris and a sticky substance, and an electric blender base with a thick, dried-on food substance. Dietary Staff BB later confirmed these areas of concern needed to be addressed. The facility's kitchen cleaning schedule documented that counters and carts were to be cleaned daily and the ice machine, refrigerators, and freezers weekly.
Failure to Maintain Resident Dignity During Personal Exposure
Penalty
Summary
The facility failed to show respect and dignity to one resident when she was observed sitting in her room with her door open and her gown and blanket pulled up to her waist, exposing her legs from her upper thighs to her feet. The resident was visible to staff, visitors, and other residents in the hallway during these observations. On one occasion, the resident stated she was unable to cover her legs with the blanket in her lap. The resident had a diagnosis of cerebral infarction and an Annual MDS documenting a BIMS score of 14, indicating intact cognition. Her records showed limited ROM on one side of her upper and lower extremities and dependence on staff for lower body dressing. The ADL/Functional Abilities CAA documented that she required staff assistance with ADLs, her ADL Care Plan stated she was dependent on staff for lower body dressing, and the EMR tasks tab documented partial/moderate to dependent staff assistance for lower body dressing. A CNA stated the resident was able to cover her legs on her own but at times would leave them uncovered, and an Administrative Nurse stated it was the expectation for staff to ensure residents were covered appropriately to ensure dignity.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to R15 and/or his representative explaining the purpose of his transfer to the hospital. R15 had a diagnosis of Parkinson's disease, was admitted from a short-term acute hospital, and had a BIMS score of 15 indicating intact cognition. His discharge MDS documented that he was discharged from the facility to a short-term acute hospital, but his EMR did not contain documentation of a written notification for the emergency transfer. Administrative Staff A stated that written notification of R15's emergency transport to the hospital had not been completed as required. The facility also failed to provide written notification to R1 and/or her representative explaining the reason for her transfer to the hospital. R1 had diagnoses of lung cancer, respiratory failure, COPD, and CHF. A nurse note documented that she was sitting on the side of the bed, wavering forward, and her oxygen level was 79% after breathing treatments were provided; she agreed to go to the hospital and was transported by ambulance. Her EMR lacked documentation of a written notification to the resident and/or her representative regarding the transfer. Staff interviews indicated that the social services staff and administrative nurse were unaware of the regulation to notify the resident or representative in writing, and the facility had not been notifying the ombudsman.
Failure to Update Care Plan for Cancer and Cancerous Lesions
Penalty
Summary
The facility failed to revise a resident’s care plan to include interventions for a diagnosis of cancer and cancerous lesions. The resident’s EMR documented lung cancer, respiratory failure, and COPD, and the 10/09/2025 MDS recorded a BIMS of 15, dressing treatments, and a diagnosis of cancer. The care plan dated 04/23/18 addressed risk for skin breakdown and included daily skin monitoring and monthly skin assessments, but it did not document cancerous skin lesions or lung cancer. The resident’s physician orders included daily wound care to the thigh with Vashe, calcium alginate, 4x4, Xeroform, ABD pad, and ACE wrap. Additional records documented squamous cell carcinoma in the right lung, a cancerous wound on the left thigh, plans to start chemotherapy, port placement, metastatic squamous cell carcinoma with ongoing bleeding from the left thigh and severe anemia, and initiation of Keytruda. Nursing documentation also noted copious bleeding during a dressing change, and staff stated that the wound and cancer should have been documented in the care plan but were not.
Failure to Provide Oral Care to a Resident Dependent on Staff
Penalty
Summary
The facility failed to provide oral care for a resident who was dependent on staff for oral hygiene. The resident had a diagnosis of cerebral infarction and cognitive testing documented a BIMS score of 14, indicating intact cognition. Her annual and quarterly MDS assessments showed she required setup and clean-up assistance with oral hygiene, and the ADL care plan revised 11/07/25 instructed staff that she was dependent on staff for oral hygiene. The facility’s ADL care plan and task records also documented that she required independent to dependent staff assistance with oral care. During observation on 12/01/25 and 12/02/25, the resident had dried-on food debris around her mouth, and her toothbrush and bathroom sink were dry. The resident stated she was unable to brush her teeth on her own and that staff did not assist her, and she wanted her teeth brushed every morning and before bed. A CNA stated the resident was able to brush her teeth on her own and confirmed she did not offer to brush the resident’s teeth as part of morning cares. An administrative nurse stated it was the expectation for staff to assist residents with oral care when needed, and the facility policy stated staff shall provide the necessary services to maintain oral hygiene for a resident unable to carry out ADLs independently.
Failure to Monitor Skin Tears and Manage Constipation
Penalty
Summary
The facility failed to monitor skin issues for a resident with a history of CVA who was dependent on staff for transfers and had limited ROM on one side. The resident developed skin tears to the left hand and wrist during transfers, and the EMR documented wounds measuring 1.0 x 0.1 cm and 4.0 x 1.5 cm with minimal serosanguineous and serous drainage. The wound documentation did not identify which measurement was the length or width, and the record lacked further documentation of the wounds. The resident had bandages on the left hand and forearm, and staff stated the skin tears occurred when the resident was transferred with a full-body lift and the arm became caught between the resident's body and the wheelchair arm. The facility also failed to administer PRN medication and assess for constipation for a resident with Alzheimer's disease who was rarely understood, had memory problems, and was incontinent of bladder but continent of bowels. The resident's care plan identified risk for constipation related to medication use and directed staff to monitor and document bowel movements every shift, with a bowel assessment and protocol initiation if no bowel movement occurred in three days. The physician ordered Fleet Oil Enema rectally every 24 hours as needed for constipation. Review of bowel movement documentation showed the resident went eight consecutive days without a bowel movement and/or treatment, and there was no medication given for constipation and no assessment documented during that period.
Call Light Not Kept Within Reach and Wheelchair Used Without Foot Pedals
Penalty
Summary
The facility failed to keep R4’s call light within reach. R4 had diagnoses of dementia, depression, and anxiety, and his 09/23/25 MDS documented a BIMS score of 4, indicating severe cognitive impairment. His care plan identified him as at risk for falls related to a catheter, weakness, and decreased safety awareness, and an intervention directed staff to encourage him to use the call light for assistance. However, during multiple observations on 12/01/2025 and 12/02/2025, R4 was in bed with the call light on the floor along the wall at the head of the bed, despite a sign in the room telling him to call for help. Staff later entered the room, assisted with care, and left with the call light still on the floor. A CNA stated that R4 uses the call light and sometimes yells out for help, and an administrative nurse stated that R4 should always have his call light within reach. The facility also failed to ensure R45 had wheelchair pedals when staff propelled him in his wheelchair. R45 had diagnoses of TBI and epilepsy, and his care plan stated he was dependent on staff assistance with wheelchair mobility after a recent fall with fracture and total left hip replacement. On 12/03/2025, staff directed R45 to his room and then pushed him in his wheelchair without foot pedals, including to and from the bathroom. During this time, R45 remained leaning forward with his eyes closed, and his feet were at times lightly touching the floor. Later that morning, a nurse placed the foot pedals on the wheelchair and stated that R45 was not care planned to be pushed without them. Staff interviews confirmed that wheelchair pedals should be used whenever a resident is pushed in a wheelchair, and the facility’s Safe Transport of Residents in Wheelchairs document stated that leg rests must be attached and positioned appropriately whenever staff are pushing a resident in a wheelchair.
Failure to Hold BP Medication When SBP Was Below Ordered Parameters
Penalty
Summary
The facility failed to follow physician orders for blood pressure monitoring when administering metoprolol to a resident with HTN. The resident had intact cognition with a BIMS score of 15 and was documented as having HTN on the MDS and care plan. The HTN care plan instructed staff to hold the medication if systolic blood pressure was less than 110, and the physician order for metoprolol 50 mg by mouth twice daily also directed staff to hold the medication if SBP was less than 110. Review of the MAR for 11/01/25 through 11/30/25 showed staff administered metoprolol on seven occasions when the resident's SBP was below 110. During interview, the CMA confirmed the medication had been given when the resident's SBP was out of the ordered parameters. The Administrative Nurse stated it was the expectation for staff to hold medications when the SBP was out of parameters. The facility policy required medications to be administered as ordered by the physician and in accordance with professional standards of practice.
Inadequate Hand Hygiene During Resident Peri Care
Penalty
Summary
The facility failed to use adequate hand hygiene during resident care. During an observation on 12/03/2025 at 12:56 PM, a CMA and an LN entered a resident’s room and donned gloves and gowns before assisting with a two-person stand-pivot transfer and peri care. While providing care, the LN touched the trash can and moved trash without changing gloves, then obtained a brief and wipes from the bedside stand while still wearing the same soiled gloves. The LN also wiped the resident’s peri area and applied cream while wearing the soiled glove, and later removed soiled gloves and put on clean gloves without performing hand hygiene. The same observation showed the staff handling both dirty and clean items during the resident’s care without consistent hand hygiene between tasks. The LN cleaned the opening and catheter tubing and applied petroleum jelly to the urethral opening after changing gloves without hand hygiene. At 1:19 PM, the LN verified she did not wash her hands when removing gloves or before putting on new gloves, and confirmed she had not completed hand hygiene between dirty and clean areas while assisting with peri care. Administrative Nurse D stated staff were expected to perform adequate hand hygiene, including when removing gloves prior to applying clean gloves. The facility’s infection control policy required hand hygiene before and after resident contact, after touching contaminated items, after removing gloves, and when moving from contaminated to clean body sites during resident care.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to display posted staffing information that included the required data, specifically the actual nursing hours worked for the 47 residents in the facility. Review of the Daily Staffing Sheets from 11/03/25 through 12/03/25 showed that the actual hours worked had not been completed on the daily staffing sheets. On 12/03/25 at 10:30 AM, Administrative Nurse D confirmed that the facility had not completed the actual hours on the nurse staffing sheets as required. The facility policy, Nurse Staffing Posting Information, implemented 12/03/25, stated that the Nurse Staffing Sheet will be posted daily and will contain the total number and the actual hours worked by nursing staff.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to ensure a safe, homelike environment in areas used by residents, visitors, and staff, including the kitchen floor. During observation, numerous ceiling tiles in the east residential hall were flaked, cracked, or broken, and two ceiling tiles outside one resident’s room were damaged with a ceiling tile track hanging down. Several ceiling tiles outside another resident’s room were also damaged and needed replacement or repair. Cracks were also observed extending from the top of the resident door frame to the ceiling in multiple resident rooms. In the facility entrance common area and the south resident hall, numerous ceiling tiles were broken, cracked, and/or stained, and several ceiling tile tracks were damaged and/or hanging down. An initial kitchen tour showed a build-up of food debris around the perimeter of the kitchen floor. Maintenance staff stated he routinely observed ceiling tiles throughout the building and replaced them if they were damaged, looked bad, or had stains. Administrative staff stated the facility was expected to be fresh and clean, and that damaged items should be addressed with a plan to repair them; staff were expected to identify maintenance or environmental concerns and submit work orders. Dietary staff confirmed the kitchen floor was in poor condition and needed to be replaced. The facility policy stated it would provide a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 84 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baxter Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Galena Nursing & Rehab Center | 4.3 mi | ★★★★★ | 3 | 1 |
| Communities Of Wildwood Ranch | 6.2 mi | ★★★★★ | 0 | 0 |
| Westgate | 6.2 mi | ★★★★★ | 1 | 0 |
| Higher Call Nursing Center | 8.2 mi | ★★★★★ | 3 | 0 |
| Aspire Senior Living Joplin | 8.8 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Quaker Hill Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.