Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Alpine Breeze Health And Wellness during CMS and state inspections, most recent first.
A resident with mild cognitive impairment and a known elopement risk left a secured memory care unit after the entry door was left unlatched. The resident used a walker, accessed the elevator, and exited through another hall while an alarm on that door was temporarily disabled for vendor maintenance. Law enforcement later found the resident at a nearby barbershop and returned the resident to the facility without injury.
Two residents sharing a room were involved in an assault when one resident with a long-standing history of schizophrenia, schizoaffective disorder, antisocial personality disorder, hallucinations, delusions, and documented potential aggression related to spiritual beliefs struck a cognitively impaired roommate with cerebral palsy and stroke sequelae in the face while the roommate was sleeping. The aggressor had a PASRR Level II showing paranoid ideation and psychosis, prior notes of spiritual battles and metaphysical threats, and a recent failed GDR of antipsychotic medications, with the care plan identifying risk of aggression when perceiving others as the devil. During the incident, the aggressor exhibited delusional, religiously preoccupied speech about the roommate being the devil, while the injured resident presented to staff with facial bleeding and later was found to have facial contusions and an intraoral laceration requiring sutures. Despite the facility’s abuse policy defining abuse to include resident-to-resident altercations and physical abuse such as hitting and punching, leadership later stated they did not view the event as abuse or intentional, even though the victim reported being punched multiple times in the face after refusing a sexual statement from the roommate.
Failure to provide individualized and cognitively appropriate activities was cited after staff did not tailor activities to a resident with dementia, schizoaffective disorder, and cognitive communication deficits who was often bed-bound and rarely able to make needs known. The resident’s activity record lacked documentation of preferred or one-on-one activities, and observations showed the resident lying in bed while activity staff did not attempt engagement. On the memory care unit, staff were mainly observed in the activity office or handing out snacks and drinks, while the DON and Administrator had to initiate resident engagement; interviews confirmed limited interaction, no consistent one-on-one programming for bed-bound residents, and use of the same activity calendar for all residents.
Food service sanitation was not maintained in the kitchen, as expired salad mix was found in the walk-in refrigerator, water was on the refrigerator floor, and the walk-in freezer had ice buildup on the ceiling and floor. Corn and other food were also on the freezer floor, and a black hose connected to the cooling unit was falling apart with insulation sticking out of it. The DM stated the facility received one truck a week and the truck driver would clean out expired food and restock new food.
Unsafe and Broken Plumbing Fixtures: The facility failed to keep a faucet in a resident room in good repair and failed to keep a cleanout cover on the 300 Hall securely attached to the cleanout valve. Surveyors observed the cleanout cover move when stepped on, and the faucet had a broken handle and a leak in the drainpipe. Maintenance staff said they were not aware of the issues, and the Maintenance Director said the facility does not really check cleanout covers unless a problem is reported.
Absent Negative Airflow in Multiple Resident Restrooms: Surveyors observed that multiple resident room restrooms and shared restrooms did not have negative airflow when tested with tissue paper at the ceiling vents. The issue was found in numerous rooms across the facility, potentially affecting 44 residents. The Regional Maintenance Supervisor was unsure why ventilation worked in some rooms but not others, and the Facility Maintenance Director said negative airflow had not been checked in resident rooms, with the last known check occurring in 2024 by a former maintenance employee.
A physician did not respond to the consultant pharmacist’s recommendation for a gradual dose reduction of two psychotropic medications for a resident with anxiety disorder, personality disorder, schizophrenia, and depression. The resident remained on active orders for Abilify and Cymbalta, while the record showed no documented gradual dose reduction attempt or clinical rationale for not reducing the medications. Staff interviews confirmed the expectation that the physician should document a response to the pharmacist’s recommendation.
Incomplete fall documentation and unsafe Hoyer lift transfer: A resident with stroke-related deficits and high fall risk had an unwitnessed fall, but the incident report and post-fall huddle were left incomplete and did not accurately reflect the later-discovered fracture, pain, swelling, non-weightbearing status, or orthopedic care. In a separate event, a CNA attempted a Hoyer lift transfer alone for a resident who required substantial assistance, even though two staff were required; the resident was left suspended in the air, cried out when a leg caught on the lift, and asked to be returned to bed.
Improper Catheter Bag Positioning: A resident with an indwelling catheter was observed with the catheter bag and tubing lying in the bed between the legs at the same level as the bladder rather than below it. The resident’s care plan directed staff to keep the catheter and tubing below the bladder, and staff interviews confirmed the bag should be hung on the side of the bed at all times and never left on the bed or floor except during a sterile change.
Infection control failures occurred during PEG tube care for residents with PEG tubes and EBP precautions. For one resident, TF tubing was not changed when new formula was hung as expected, and for another resident, an RN administered meds via PEG and changed the PEG dressing without wearing a gown despite EBP requiring gown and gloves for direct contact care. The residents were dependent on tube feeding and had severe cognitive impairment, and staff interviews confirmed that gown use and 24-hour tubing changes were expected.
Tracheostomy care was not completed according to orders and facility procedure for a resident with a trach, dysphagia, and muscle weakness. An ADON did not don the required gown on entry for EBP, handled sterile trach care supplies with bare hands, failed to sanitize hands after dirty-to-clean tasks, and inserted a new inner cannula without cleansing the trach site after removing the soiled cannula.
Failure to document hospice communication occurred for a resident with anoxic brain damage and dysphagia who was on hospice and severely cognitively impaired. The facility’s hospice agreement called for communication and documentation between hospice and facility staff, but the hospice communication book had no notes, while staff interviews showed communication was occurring by phone and that hospice was supposed to document visits and observations in the book.
A resident with a history of behavioral altercations became agitated during a supervised smoke break and threw a rock intended for another resident, but instead struck a third resident on the head, causing a laceration that required hospital evaluation. The incident occurred despite prior documentation of behavioral issues and interventions, and both the aggressor and the injured resident were cognitively intact at the time.
The facility failed to pay a water service vendor on time, resulting in the water being shut off and affecting all residents. Staff, including CNAs, were not notified in advance and discovered the lack of water while providing care, having to use hand sanitizer until service was restored. The issue arose during a transition between billing companies, with the administrator and account manager unaware of the payment status due to delays and lack of training on a new system.
A CNA misappropriated $617.89 from a resident's bank account after being given access to the resident's debit card to order food. The CNA used the card for multiple unauthorized transactions, including Cash App withdrawals, despite facility policies prohibiting such actions. The incident was discovered when the resident and a family member reviewed the account and found charges not authorized by the resident.
A resident with multiple diagnoses was improperly discharged from an LTC facility without a proper notice that included appeal rights and discharge location. The facility discharged the resident to a hospital due to safety concerns but failed to comply with regulatory requirements, leading to the dismissal of the discharge by the Missouri DHSS Appeals Unit.
A resident was not allowed to return to the facility after hospitalization, despite being stable and ready for discharge. The facility cited safety concerns due to the resident's behavior and intentions to become pregnant. The discharge notice was deemed inadequate, leading to legal actions and an amended discharge notice.
Elopement From Secured Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision and effective measures to prevent elopement for one resident on the secured memory care unit. The resident had mild cognitive impairment of unknown origin, was assessed as high risk for elopement, could ambulate and propel self or wander, and had a history of intentionally or unintentionally attempting to leave the community. The care plan identified the resident as admitted to the Garden Unit due to elopement risk and included interventions such as documenting behavior patterns and triggers, offering companionship, reassurance and redirection, monitoring for contributing factors like restlessness in late afternoon, increased anxiety, or packing belongings, and providing structured activities during high-risk times. On the evening of the incident, staff reported that the resident left the memory care unit after the unit entry door was not fully latched. The resident was able to open the door, access the elevator, travel to another floor, and exit the facility through a 400 hall door. The resident stated he/she did not recall hearing an alarm and reported exiting through the memory care unit entry door, using the elevator, and then leaving through the 400 hall exit door. The facility identified that the stop sign alarm on that hall did not activate because routine maintenance was being performed by an outside vendor, and the 400 hall did not have the banner barrier that was present on other halls. The resident was later found by law enforcement at a nearby barbershop after the owner contacted police because the resident said, "I'm not sure where to go." The resident was unable to tell officers where he/she lived and was returned to the facility without injury. The administrator stated another resident's family member had left the memory care unit door unlatched, the door was flush and could not be visually confirmed as latched, staff were busy with other residents after dinner, and staff would not necessarily have noticed the resident was gone right away.
Resident-to-resident assault following unmanaged psychotic and delusional behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a cognitively impaired resident with cerebral palsy and sequelae of cerebral infarction was struck in the face by a roommate while sleeping. The assaulted resident had been admitted days earlier and had an MDS indicating cognitive impairment, with a care plan noting impaired cognitive function/dementia and impaired thought processes with neurological symptoms. In the early morning hours, this resident approached the south nurses’ station with visible bleeding from the nose, appeared upset, and reported that the roommate had woken them, proclaimed they were the devil, and struck them in the face while they were in bed. The charge nurse observed bleeding, assisted with cleaning the face, applied ice, and administered PRN Tylenol, and the resident was placed at the nurses’ station for close observation. The aggressor resident had a documented long-standing history of serious psychiatric diagnoses, including schizophrenia (paranoid type), schizoaffective disorder (bipolar type), antisocial personality disorder, personality disorder, insomnia, and positive symptoms of schizophrenia such as auditory and visual hallucinations, delusional thinking, and psychosis. The PASRR/MI Level II evaluation documented paranoid ideation, delusional thinking, reality testing problems, and suspiciousness of others, including not trusting other residents. Progress notes referenced complaints of spiritual battles, metaphysical spears, and a foreign presence attempting to steal money, as well as increased delusions and hallucinations when antipsychotic medications such as Risperdal or Clozaril were decreased, and poor response to Zyprexa. The resident’s care plan identified a behavior problem of potential aggression related to spiritual beliefs that others may be the devil or working with the devil, with interventions including administering psychotropic medications as ordered and monitoring for side effects and effectiveness. A recent GDR of psychotropic medication had been attempted and failed shortly before the incident. On the night of the incident, progress notes for the aggressor resident documented that, following the altercation, the resident was alert but exhibited delusional and religiously preoccupied speech, stating that the event was about the roommate being the devil, that they had been awake for days trying to trap the devil’s power, and that they were trying to do the right thing. The resident reported believing the roommate was using the devil’s power and described paranoid and delusional content consistent with prior documented symptoms. The assaulted resident’s trauma-informed care documentation indicated they had been physically assaulted, and a skin check showed a laceration to the inner lip and minor swelling to the left eye. An emergency provider report later documented head and facial contusions, intraoral laceration, left facial and periorbital soft tissue swelling, and a 2.5 cm inner lower lip laceration requiring sutures. A police report recorded the victim’s account that the roommate approached while they were in bed, made a sexual statement, and then punched them multiple times in the face while repeatedly shouting, “I’m the devil,” until the victim was able to push the aggressor away and escape to the nurses’ station. Facility leadership, including the DON and Administrator, later stated they did not anticipate such an event, did not believe the aggressor acted with intent, and did not consider the incident to be abuse, despite the facility’s abuse policy defining abuse to include resident-to-resident altercations and physical abuse such as hitting and punching.
Failure to Provide Individualized and Cognitively Appropriate Activities
Penalty
Summary
The facility failed to provide individualized and customized activities based on residents’ previous lifestyles, preferences, and comforts, failed to ensure individualized activities for a bed-bound resident who was unable to participate in group activities, and failed to provide cognitively appropriate activities for residents in the memory care unit. The cited concerns involved one sampled resident and potentially affected all 27 residents residing on the memory care unit. The facility’s activity policy stated that activities should be based on each resident’s comprehensive assessment, care plan, and preferences, and could include one-on-one and person-appropriate programs. Resident #118 had diagnoses including vascular dementia, schizoaffective disorder bipolar type, and cognitive communication deficit. The resident’s MDS showed moderate cognitive impairment, with the resident sometimes understanding others and rarely being able to make needs known. The activity log for July 2025 showed attendance at 10 of 18 social and party opportunities, but there was no documentation of preferred activities or one-on-one activities offered. The resident was observed lying in bed on multiple occasions, including with a meal tray in the room and later with the blanket over the head, and did not verbally respond when approached. On the memory care unit, the posted calendar listed arts and crafts, a popcorn social, and puzzles and pondering, but observations showed activity staff in the activity office with the door shut while residents were in common areas. The DON and Administrator were observed on the unit, and the Administrator had to obtain activity items and initiate music and dancing with residents while activity aides did not participate. Staff interviews indicated that activity staff were mainly seen handing out snacks or drinks, were not consistently interacting with residents during scheduled activity times, had not seen one-on-one activities for bed-bound residents, and were using the same activity calendar for all residents. The Activities Director stated that one-on-one activities such as nail spa day and talking with the resident were offered, but also said Resident #118 did not like group activities and had been offered nail spa day that day and declined.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
Food service sanitation was not maintained in the kitchen areas, including the walk-in refrigerator and walk-in freezer. During observation, expired salad mix with an expiration date of 7/15/25 was found in the walk-in refrigerator. Water was observed on the floor of the walk-in refrigerator, and the walk-in freezer had ice buildup on the ceiling and floor. Corn and other food were observed on the rubber rug on the floor of the walk-in freezer. The walk-in freezer also had a black hose connected to the cooling unit that was falling apart with insulation sticking out of it. During interview, the Dietary Manager stated the facility received one truck a week and the truck driver would clean out expired food and restock new food, and that the kitchen was cleaned every day by staff. The facility census was 140 residents, and the observations were made during breakfast meal preparation while food service was being prepared.
Unsafe and Broken Plumbing Fixtures
Penalty
Summary
The facility failed to maintain a faucet in resident room [ROOM NUMBER] in good repair and failed to maintain the cleanout cover on the 300 Hall securely attached to the cleanout valve. Observation on 8/13/25 at 10:35 A.M. and 3:39 P.M. showed the cleanout cover moved when it was stepped on. During an interview on 8/13/25 at 3:39 P.M., the Facility Maintenance Director said he/she did not know the cleanout cover needed to be tightened. During a phone interview on 8/26/25 at 12:19 P.M., the Facility Maintenance Director said the facility typically does not have issues with cleanout covers and does not really check them, but would address them if a loose or slack cleanout cover was reported. Observation on 8/13/25 at 3:32 P.M. and 8/15/25 at 9:31 A.M. showed the faucet in resident room [ROOM NUMBER] had a broken handle and a leak in the faucet drainpipe. During an interview on 8/13/25 at 3:33 P.M., the Facility Maintenance Person said he/she did not know about the broken handle or the leak in the pipe from the faucet in resident room [ROOM NUMBER].
Absent Negative Airflow in Multiple Resident Restrooms
Penalty
Summary
The facility failed to ensure negative airflow was present in required areas such as resident room restrooms and soiled utility rooms. Based on observation and interview, surveyors found the absence of negative air flow in multiple restrooms, including the shared restroom of resident rooms 310/308, the shared restroom of resident rooms 306/304, and the shared restroom of resident rooms 302/300, as well as in numerous other resident room restrooms across the facility. The report states that this practice potentially affected 44 residents, and the facility census was 140 residents. Air flow was tested by holding one piece of tissue paper to the ceiling vent; if the paper was drawn to the vent, negative air flow was present, and if the paper fell, negative airflow was absent. On 8/13/25 and 8/14/25, surveyors observed multiple restrooms where the tissue paper fell, indicating absent negative airflow. During interview, the Regional Maintenance Supervisor said he/she was not sure why ventilation worked in some resident rooms and did not work in other rooms. The Facility Maintenance Director stated he/she had not checked for negative airflow in the ceiling vents in resident rooms and last remembered it being checked in 2024 by an assistant maintenance person who was no longer employed at the facility.
Physician Did Not Respond to Gradual Dose Reduction Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the physician responded to the consultant pharmacist’s recommendation for a gradual dose reduction of two psychotropic medications for one resident. The deficiency involved a resident admitted with diagnoses including anxiety disorder, personality disorder, schizophrenia, and depression. The resident’s medication regimen included Remeron 30 mg at bedtime, Cymbalta 60 mg daily, and Abilify 15 mg daily, and the pharmacist’s medication regimen review on 6/30/25 stated that the resident had been taking these medications for quite some time and asked that the current doses be evaluated and a dose reduction be considered. Record review showed no documentation that the physician attempted a gradual dose reduction of Cymbalta or Abilify, and no documentation explaining why a gradual dose reduction was not clinically indicated or not in the resident’s best interest. The annual MDS dated 7/8/25 showed the resident was alert, oriented, cognitively intact with minimal confusion, received antipsychotic and antidepressant medications during the lookback period, used antipsychotics on a routine basis, had not had a gradual dose reduction attempted, and had no physician documentation that a gradual dose reduction was clinically contraindicated. The pharmacy drug regimen review response dated 7/9/25 showed the physician agreed and changed the Remeron order to 15 mg, but did not respond to the pharmacist’s recommendation for a gradual dose reduction for Cymbalta or Abilify. The resident’s August 2025 physician order sheet still showed active orders for Abilify 15 mg daily for anxiety and Cymbalta 60 mg daily for depression. During interviews, nursing staff stated that pharmacist recommendations were expected to be documented and that the physician should respond to gradual dose reduction recommendations, but the DON stated the physician should document the clinical rationale if not agreeing and should respond within 7 days or during the month of review.
Incomplete fall documentation and unsafe Hoyer lift transfer
Penalty
Summary
The facility failed to ensure that fall investigations and post-fall documentation were complete and accurate for a resident who had an unwitnessed fall with injury. The resident had multiple diagnoses including stroke with right-sided paralysis, diabetes, COPD, anxiety, unsteadiness on feet, difficulty walking, lack of coordination, blindness in one eye, and contractures. The resident’s care plan identified fall risk related to unsteady gait and balance, psychotropic medications, and prior falls, and also noted poor communication, poor impulse control, and poor decision-making abilities. After the unwitnessed fall, the incident report documented that the resident was found lying on the floor next to the bed, said he/she was trying to transfer to the wheelchair and missed it, and denied hitting the head. However, the incident report was incomplete because sections for predisposing factors and additional information were left blank, and the report stated neurological checks were initiated without documenting vital signs. The post-fall huddle also had multiple blank sections, including behaviors, factors observed at the time of the fall, footwear, last staff check, pain, pain medication, and other fall-related factors. The resident’s later documentation showed the injury was more serious than initially recorded. Nursing notes and subsequent records showed pain, swelling, x-ray findings of a fracture, non-weightbearing status, orthopedic follow-up, and therapy involvement, but the post-fall observation documentation did not reflect the fracture, treatment, change in mobility status, or current physician orders. The record also contained inconsistent accounts of the fall, including statements that the resident had been drinking alcohol and attempted to transfer or walk without assistance. The facility also failed to maintain a safe transfer for another resident during a Hoyer lift transfer. The resident had diagnoses including morbid obesity, muscle weakness, difficulty walking, and need for assistance with personal care, and required substantial to maximal assistance with toileting, bathing, dressing, and wheelchair mobility. A CNA was observed transferring the resident alone in a Hoyer lift from bed to a motorized wheelchair even though staff stated two people were required for such transfers. The resident was suspended in the air, asked to be put back in bed, and cried out when a leg became caught on the lift while the CNA continued trying to position the resident into the wheelchair before eventually returning the resident to bed.
Improper Catheter Bag Positioning
Penalty
Summary
Failure to provide appropriate catheter care was identified for one resident with an indwelling catheter. The resident was admitted with diagnoses including kidney disease, uropathy, and need for personal assistance. The resident’s MDS showed the resident was alert, oriented, cognitively intact with minimal confusion and used an indwelling catheter for urination. The care plan directed nursing staff to provide catheter care each shift and to position the catheter and tubing below the level of the bladder and away from the entrance room door. The physician’s orders included catheter change as needed for leakage, obstruction, accidental removal, or when ordered. During observations, the resident’s catheter bag and tubing were seen lying in the resident’s bed between the resident’s legs at the same level as the bladder and not below it, first while the resident was resting in bed and again several hours later. Yellow fluid was present in the tubing. Staff interviews indicated the catheter bag was supposed to be hung on the side of the bed below the bladder at all times, and that CNA rounds every two hours should include checking that it was positioned correctly. An LPN stated the bag should never be on the bed except during a sterile catheter bag change and should never be found on the floor. The DON stated the catheter bag should be below the waist and bladder at all times and should never be laid on the bed or floor.
Infection Control Failures During PEG Tube Feeding and Site Care
Penalty
Summary
The facility failed to maintain infection control practices during enteral feeding care for a resident with a PEG tube who was admitted with adult failure to thrive and protein-calorie malnutrition and was dependent on tube feeding and water flushes for nutrition. The resident’s care plan and physician orders directed PEG tube site care, monitoring for infection, and enteral feeding via pump. The resident’s MDS showed severe cognitive impairment and that tube feeding was the main source of nutrition. For one resident, surveyors observed the tube feeding pump was not running and not connected at one point, and the formula bottle and tubing were dated on different days. On later observations, the formula bottle had been changed while the tubing remained dated from the prior day, and the tubing had not been changed when a new bottle of formula was hung. The resident’s EBP signage required gown and gloves for direct contact care, and when the RN later reconnected the tube feeding, the RN washed hands, donned gloves and a gown, and primed and dated new tubing. For another resident with Huntington disease, adult failure to thrive, severe cognitive impairment, and PEG tube dependence, the physician orders required daily PEG site care and EBP with gown and gloves for high-contact care. During observed medication administration through the PEG tube, the RN washed hands, used gloves, checked tube placement, disconnected the feeding tubing, flushed the tube, and administered medications, but did not wear a gown during the medication administration process. The RN then changed the PEG tube dressing using the same gloves, removed the old split dressing, cleansed the site, changed gloves, and applied a new split gauze pad, but again did not wear a gown during the dressing change. Staff interviews stated that gown and gloves were expected for direct contact care for residents on EBP, and that licensed nursing staff were responsible for PEG tube feeding, medication administration, site care, and changing tube feeding tubing every 24 hours.
Tracheostomy Care Performed Without Required Infection Control Practices
Penalty
Summary
Failure to provide safe and appropriate respiratory care was identified for a resident with a tracheostomy, dysphagia, and muscle weakness who was alert, oriented, and cognitively intact with minimal confusion. The resident had physician orders for daily tracheostomy care, daily disposable inner cannula changes, stoma cleansing with normal saline, and Enhanced Barrier Precautions (EBP) with gown and gloves for high-contact resident care activities. During observation, the resident was sitting in a wheelchair, wearing oxygen, and had a clean tracheostomy with split gauze in place. During tracheostomy care, the Assistant Director of Nursing (ADON) did not follow the facility's procedure. The ADON re-entered the room holding a gown and an unopened tracheostomy care container, but placed the packaged gown on a dresser without donning it. The ADON then opened the tracheostomy care container, donned sterile gloves, and performed care while using sterile supplies. The ADON opened and poured saline into the container, placed sterile cloths in the solution, cleaned around and under the tracheostomy with cotton swabs and wet cloths, and then placed a clean split gauze under the tracheostomy without removing the sterile gloves or washing/sanitizing hands after the dirty-to-clean task. The ADON later returned to the room, donned the gown, and resumed tracheostomy care. After removing the inner cannula, which had yellowish phlegm, the ADON inserted a new inner cannula but did not cleanse the outside and inside of the tracheostomy before reinsertion. The ADON stated he/she had used bare hands to place sterile cloths down before donning sterile gloves, did not remember not wearing the gown on the first entry, did not sanitize hands after discarding soiled items, and forgot to clean the tracheostomy before inserting the new inner cannula.
Failure to Document Hospice Communication
Penalty
Summary
The facility failed to ensure communication was established and completed between the facility and hospice nursing staff for one sampled resident. The resident had diagnoses of anoxic brain damage and dysphagia, began hospice services on 7/25/25, and was severely cognitively impaired and never or rarely made decisions according to the MDS dated 8/7/25. Review of the hospice communication book on 8/18/25 showed no documentation of any communication notes between hospice and the facility. The facility’s Hospice Service Facility Agreement and Nursing Facility Services Agreement both described a communication process between the facility and hospice, including documentation of communications to ensure resident needs were addressed and met 24 hours per day. During interviews, a CNA stated CNAs did nothing with hospice and had seen nurses communicate with hospice by phone. An RN stated communication occurred by phone and that hospice was supposed to fill out information in the book about their presence and observations. The DON stated hospice was to communicate through the book, nurses were to check in with leadership, and the DON was responsible for making sure information was entered in the communication book.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident struck another on the head with a rock, resulting in a laceration and a hospital visit. The incident occurred outside during a supervised smoke break, where one resident became agitated at another and, after a verbal altercation, threw a rock intended for a different resident but instead hit a third resident. The injured resident sustained a 3 cm laceration to the back of the head and required hospital evaluation due to being on blood thinners. Prior to the incident, the resident who threw the rock had a documented history of altercations with other residents, including being the instigator in a previous dispute and having another altercation just days before the event. Care plans and assessments noted these behavioral issues, and interventions such as increased supervision and trauma-informed assessments were implemented after previous incidents. However, despite these measures, the resident was able to access an area where rocks were present and engage in another altercation. Interviews and record reviews confirmed that the resident who threw the rock was cognitively intact but had a history of mood and anxiety disorders, as well as a history of behavioral issues with peers. The injured resident was also cognitively intact and had no involvement in the altercation prior to being struck. The facility's policies defined abuse to include resident-to-resident altercations resulting in physical harm, and the incident met this definition as the action was deliberate, even if not intended to harm the specific resident who was injured.
Water Service Disruption Due to Untimely Vendor Payment
Penalty
Summary
The facility management company failed to ensure timely payment to a vendor responsible for providing water services, resulting in the facility's water being shut off for non-payment. The facility had received a 10-day shut-off notice from the vendor, which was forwarded to the facility management account manager and the Chief Financial Officer. Despite receiving multiple late and shut-off notices, payment was not made in time, and the water was disconnected at 9:02 A.M., affecting all 113 residents in the building. The administrator and staff were unaware of the impending shut-off until the water was already turned off. Interviews revealed that the facility was in a transition period between billing companies, which led to confusion and delays in processing the water bill. The original bill was sent to the previous billing company and was not received by the new billing company until the shut-off notice was forwarded. The account manager indicated that a check was cut and mailed, but it was assumed it would arrive before the shut-off deadline. The administrator had not yet received training on the new bill-paying system, and the vendor responsible for water services had not been set up for auto-pay at the time of the incident. During the water shut-off, staff members, including CNAs, were not notified in advance and discovered the lack of water while performing resident care tasks. They had to use hand sanitizer for hygiene until the water was restored. The deficiency was determined to be at the immediate and serious jeopardy level due to the impact on resident care and facility operations.
Misappropriation of Resident Funds by CNA
Penalty
Summary
A certified nurse aide (CNA) misappropriated funds from a resident who was cognitively intact and responsible for their own finances. The resident had asked the CNA to assist with ordering food through Door Dash, as the resident was unfamiliar with the process. The CNA subsequently gained access to the resident's debit card and used it for multiple unauthorized transactions, including Cash App withdrawals and other purchases, totaling $617.89 that were not authorized by the resident. The resident only authorized the CNA to use the card for the specific food order and did not permit any other use. The incident was discovered when the resident noticed their card was not working and contacted a family member to review the account. Upon reviewing the bank statement, the resident and family member identified several unauthorized transactions, including those associated with the CNA's name on Cash App. The resident reported the incident to facility administration, who then initiated an investigation. The CNA denied using the resident's debit card for unauthorized purchases but admitted to helping the resident order food on the resident's phone. The CNA had previously received training on abuse, neglect, and misappropriation of resident property, and had signed off on the relevant policies. The facility's policies required that staff not use residents' credit or debit cards or non-cash forms of payment on personal devices, and that any transaction involving resident funds be documented with a receipt. Despite these policies, the CNA exploited their access to the resident's financial information, resulting in the misappropriation of funds. The incident was reported to law enforcement, and the facility's administration, DON, and other relevant parties were notified. The resident expressed feelings of distrust and anger following the event, which affected their overall well-being.
Improper Discharge Notice and Procedure
Penalty
Summary
The facility failed to provide a proper discharge notice for a resident, which included the right to appeal and the location to which the resident was transferred. The resident, who was cognitively intact, had multiple diagnoses including paraplegia, depression, PTSD, and bipolar disorder, and required assistance with personal care. The facility's policy required a 30-day notice of discharge, including the reason, effective date, and contact information for the Ombudsman, which was not adhered to in this case. The resident was initially discharged to a family member's home, despite the family member's refusal to accept the resident due to behavioral issues. The facility then discharged the resident to a hospital without proper notice, as confirmed by interviews with the hospital staff and the family member. The discharge notice lacked information on the resident's right to appeal, which led to the dismissal of the discharge by the Missouri Department of Health & Senior Services Appeals Unit. The facility's decision to discharge the resident was based on concerns about safety due to the resident's behavior, including bringing unknown individuals into the facility. However, the discharge process was not conducted in compliance with regulatory requirements, as the notice was deemed inadequate. The resident filed an appeal, and the facility was directed to allow the resident to remain or return to the facility due to the defective notice.
Facility Fails to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, who had been admitted with diagnoses including paraplegia, depression, PTSD, and bipolar disorder, was cognitively intact and required assistance with personal care. Despite being stable and ready for discharge from the hospital, the facility refused to readmit the resident, citing safety concerns related to the resident's behavior and intentions to become pregnant while in the facility. The facility issued an Immediate Involuntary Discharge Notice, which lacked the required information for the resident to appeal the decision. The discharge was based on the resident's alleged non-compliance with facility policies, including bringing unknown males into the facility and potentially introducing illicit substances. The facility's actions were deemed inappropriate as the discharge notice did not meet regulatory requirements, leading to the dismissal of the discharge by the Missouri Department of Health & Senior Services Appeals Unit. Interviews with facility staff and the resident revealed that the facility was not equipped to handle a resident attempting to become pregnant, and the resident's behavior was perceived as a safety risk. Despite the resident's appeal and the involvement of an attorney, the facility maintained its stance on not readmitting the resident, leading to further legal actions and the issuance of an amended discharge notice.
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Illustrative
What surveyors actually found near you
We read the 796 citations issued within 25 miles in the last 12 months — including the 23 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 Raytown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Manor Health Care Center | 2.6 mi | ★★★★★ | 6 | 0 |
| Jeanne Jugan Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Seasons Rehab And Healthcare Center | 4 mi | ★★★★★ | 2 | 0 |
| Gregory Ridge Health Care Center | 4.4 mi | ★★★★★ | 13 | 1 |
| University Health Lakewood Medical Center | 4.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.