Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Arbor View Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple complex medical and cognitive conditions was transferred from a Geri-chair to a bed by a CNA and a CMT without the use of a gait belt, despite the resident being visibly upset and resisting. Staff did not follow safe transfer techniques or the care plan, and interviews confirmed that proper procedures were not followed, resulting in a failure to ensure a safe environment and adequate supervision.
A long-term care facility failed to provide consistent showering for three residents, leading to missed hygiene opportunities and personal care issues. One resident with chronic health conditions reported going weeks without a shower, while another with diabetes and an amputation experienced hygiene-related skin problems. A third resident with cerebral palsy was observed with poor hygiene. Staff interviews revealed issues with completing shower sheets and challenges in providing showers, especially during the evening shift.
The facility failed to maintain hot food temperatures at or above 120°F for residents during meal service. Observations showed that dietary staff used open tray carts without heated food service carts, leading to improper food temperatures. The Dietary Manager acknowledged issues with tray passing and insufficient plate warmers. The facility lacked a policy or system to monitor food tray temperatures, and temperature logs were not maintained. Residents and staff reported dissatisfaction with cold and unappetizing food, and the Administrator admitted to not having a specific food service policy.
A resident with epilepsy missed five doses of their seizure medication due to a misplacement in the medication cart and a lack of communication among staff. The resident experienced a seizure, and the facility's policy did not address procedures for unavailable medication. Staff interviews revealed a breakdown in communication and adherence to protocols.
The facility revoked the Leave of Absence (LOA) rights of four residents who were their own responsible parties, following perceived violations of a policy on illegal substances, marijuana, and alcohol. The policy allowed for LOA revocation if residents were suspected of using or possessing contraband. Incidents included a resident returning drunk, another returning late from a family outing, and others attempting to leave the facility unsafely. Staff enforced the policy to protect residents and the facility, though concerns about resident rights were raised.
A facility failed to protect a resident's rights by prohibiting a family visit based on unverified assumptions of drug possession. The resident, who was cognitively intact and had multiple diagnoses, experienced a behavioral episode after the administrator refused entry to the family member without prior investigation or offering a supervised visit. The incident led to the resident being taken to the emergency room. Concerns were raised about the facility's policy on contraband and its impact on resident rights.
The facility failed to obtain written authorization for financial transactions from two residents and did not provide ongoing access to funds. A resident's withdrawal was recorded with an unauthorized signature, and another resident's signature was falsified. Additionally, a resident was unable to access funds for personal purchases due to a lack of petty cash, and the Business Office Manager confirmed cash was not always available, affecting all residents managed by the facility.
The facility failed to ensure safe smoking practices for residents requiring supervision, leading to unsupervised smoking activities. Residents with cognitive and physical impairments were observed smoking without staff supervision, contrary to their care plans and facility policy. Staff interviews revealed insufficient supervision due to staffing issues, and residents often retained smoking materials against policy.
The facility failed to maintain sanitary conditions in food storage and distribution, with observations of dirt and debris in the walk-in refrigerator and freezer, unlabeled food items, and grime buildup on kitchen equipment. Dented cans and an opened bag of powdered milk were found in the dry storage room. Interviews revealed unmet expectations for food labeling and cleanliness.
A facility failed to document and communicate essential dialysis care for a resident with end-stage renal disease. The facility missed 16 out of 31 communication opportunities and failed to document vital signs post-dialysis on three occasions. Interviews revealed inconsistencies in following dialysis care guidelines, with staff not consistently observing the resident's arm for thrill and bruit, and communication forms not being utilized as expected.
The facility failed to keep dumpsters closed and maintained to prevent pests and contain garbage. Observations showed the dumpster lid open with visible trash on multiple occasions. Interviews with the Dietary Manager, Housekeeping and Laundry Manager, Administrator, and DON indicated an expectation for staff to close the lids after discarding trash, but no sanitation policy was provided.
A facility failed to maintain infection control practices during wound care for a resident. An LPN did not sanitize hands before gathering supplies, used the same gloves for multiple tasks, and improperly handled soiled equipment. Interviews with staff revealed non-compliance with infection control policies, including using the same hand sanitizer and wound cleanser for multiple residents.
The facility's pest control program failed to address a fly infestation, affecting all 83 residents. Despite a policy requiring comprehensive pest control, invoices from December 2023 to May 2024 showed no services targeting flies. Observations revealed flies in resident rooms and common areas, with staff noting inadequate communication with the pest control provider. The issue was worsened by residents opening windows and doors, and the lack of a system to identify problem areas.
Unsafe Transfer and Lack of Supervision During Resident Handling
Penalty
Summary
Facility staff failed to perform a safe transfer for a resident with multiple complex diagnoses, including traumatic brain injury, cognitive communication deficit, muscle weakness, chronic kidney disease, aphasia, depression, schizophrenia, and PTSD. Video evidence showed that a CNA and a CMT transferred the resident from a Geri-chair to a bed without using a gait belt, despite the resident being visibly upset, screaming, and thrashing. The CNA lifted the resident by the back of the pants while the CMT held the resident's arms, and they released the resident quickly onto the bed. The transfer was not performed according to safe transfer techniques, and the resident's care plan did not include specific instructions for transfers. Interviews with facility staff revealed that CNAs are trained to walk away and return later if a resident is upset and unable to be redirected, and that a gait belt should always be used for transfers. However, the CNA involved stated she never uses a gait belt for this resident and proceeded with the transfer because the resident had been in the chair for more than two hours. The care plan lacked guidance on transfer requirements, and staff did not follow established procedures for safe resident handling, resulting in a failure to provide adequate supervision and prevent accident hazards.
Inconsistent Showering Practices in LTC Facility
Penalty
Summary
The facility failed to provide consistent care for activities of daily living (ADLs), specifically in ensuring regular showers for three residents. Resident #1, who has chronic obstructive pulmonary disease, type 2 diabetes, and Parkinson's disease, reported going weeks without a shower. Despite being scheduled for showers twice a week, records showed that Resident #1 missed six out of eight opportunities in December 2024 and six out of nine in January 2025. The resident expressed that staff often claimed they were too busy or understaffed to provide showers, and sometimes falsely marked the shower sheets as refused. Resident #2, with diagnoses including type 2 diabetes with neuropathy, chronic respiratory failure, and an above-knee amputation, was also dependent on staff for bathing. This resident reported going weeks without a shower, leading to personal hygiene issues such as body odor and skin problems. The facility's records indicated that Resident #2 missed six out of seven scheduled showers in both December 2024 and January 2025. The resident expressed embarrassment and self-consciousness due to the lack of personal care. Resident #3, who has cerebral palsy and moderate intellectual disabilities, was observed with disheveled hair and a faint smell of urine, indicating a lack of personal hygiene care. This resident was also dependent on staff for bathing and missed four out of eight scheduled showers in December 2024 and four out of nine in January 2025. Interviews with staff revealed inconsistencies in completing shower sheets and acknowledged challenges in providing showers, particularly during the evening shift. The facility's interim Director of Nursing noted that some staff were not diligent in completing shower sheets, and there were alerts in the electronic records system for residents who had not received showers in seven days.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain the temperature of hot food at or above 120 degrees Fahrenheit for 12 residents during meal service. Observations revealed that the dietary staff used open tray carts without heated food service carts for daily meals, resulting in food being served at improper temperatures. The Dietary Manager acknowledged issues with food temperatures due to untimely tray passing and the lack of sufficient plate warmers. The facility did not have a policy or system in place to monitor food tray temperatures at the time of service, and temperature logs were not maintained. Interviews with residents and staff indicated dissatisfaction with the food being served cold and unappetizing. The Dietary Manager and Administrator admitted to not having a specific food service policy, relying instead on the Missouri Food Code. The Administrator was aware of dietary issues but had not implemented a system to ensure food was served at safe and appetizing temperatures. The deficiency was identified through observations, interviews, and record reviews, highlighting the facility's failure to ensure food safety and quality for its residents.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to follow physician's orders for a resident who did not receive five doses of their prescribed seizure medication, cenobamate. The resident, who had a history of epilepsy, brain cancer, diabetes mellitus, and generalized anxiety disorder, experienced a full-body seizure lasting four minutes. The seizure occurred after the resident missed five consecutive doses of their seizure medication, which was found to be misplaced in the nurse's medication cart instead of the Certified Medication Technician (CMT) cart. The facility's policy required medications to be administered by licensed nurses or authorized staff as ordered by the physician. However, the policy did not address procedures for when medication was unavailable. The Assistant Director of Nursing (ADON) mistakenly placed the resident's cenobamate in the nurse's cart, and the CMTs failed to notify the nurses about the missing medication. The night nurses did not communicate the issue to the day shift nurses, resulting in the resident missing five doses of their medication. Interviews with facility staff revealed a breakdown in communication and adherence to medication administration protocols. The ADON admitted to placing the medication in the wrong cart, and the CMTs did not follow up with the charge nurse to report the unavailability of the medication. The Director of Nursing (DON) and other staff members acknowledged that the situation could have been avoided if proper procedures were followed, highlighting a significant lapse in the facility's medication management process.
Revocation of Resident LOA Rights Due to Policy Violations
Penalty
Summary
The facility failed to protect the rights of four residents by revoking their right to temporarily leave the facility, despite them being their own responsible parties. This action was taken in response to perceived violations of the facility's updated policy on illegal substances, marijuana, and alcohol. The policy allowed the facility to revoke Leave of Absence (LOA) privileges if residents were suspected of using or possessing contraband substances. The facility's actions were based on physician orders following incidents where residents were suspected of being under the influence or attempting to leave the premises unsafely. Resident #1, who is cognitively intact and his/her own responsible party, had their LOA privileges revoked after returning to the facility appearing drunk. The facility's administrator expressed concerns about the resident's safety when leaving the facility, as the resident would travel to a nearby gas station via a highway. Similarly, Resident #2 had their LOA privileges revoked after returning late from a family outing, and Resident #3 was stopped by staff while attempting to leave the facility in an electric wheelchair, leading to a revocation of their LOA privileges. Resident #4's LOA privileges were revoked after a violation of the smoking policy and a subsequent search of their room revealed marijuana. The facility's policy allowed for room searches and revocation of LOA privileges if contraband was found. Interviews with facility staff, including the Medical Director and Director of Nurses, indicated that the policy was enforced to protect residents and the facility from potential harm. However, the Social Worker expressed concerns about potential resident rights issues and reached out to the Ombudsman for advice, highlighting the punitive nature of the policy's enforcement.
Facility Fails to Protect Resident's Visitation Rights
Penalty
Summary
The facility failed to protect the rights of a resident by prohibiting the visitation of a family member based on an assumption that the family member was in possession of marijuana. The facility's policy on possession and use of illegal substances allows for the confiscation of items posing risks to health and safety, and the restriction of visitors suspected of bringing in illegal substances. However, the facility did not investigate the rumors or speak with the resident prior to the visitor's arrival, nor did they offer a supervised visit. The resident involved was cognitively intact and had diagnoses including anxiety disorder, muscle weakness, paraplegia, and bipolar disorder. The resident was their own responsible party. On the day of the incident, the facility's administrator refused entry to the resident's family member based on unverified reports from other residents that the family member was bringing drugs. This action led to a behavioral episode in which the resident attacked staff members and was subsequently taken to the emergency room. Interviews with the administrator and the regional nurse revealed that the facility had a policy prohibiting contraband and allowing searches of resident belongings. However, the administrator did not discuss concerns with the resident or their family, nor did they have evidence of previous issues with the family bringing in drugs. The social worker expressed concerns about potential resident rights issues with the new policy, which she felt was punitive. The resident, who was hospitalized for an unrelated issue, expressed dissatisfaction with the facility and did not wish to return.
Failure to Obtain Authorization and Provide Access to Resident Funds
Penalty
Summary
The facility failed to obtain written authorization for financial transactions from two residents, which was identified during a review of the Resident Trust Ledger. For one resident, a withdrawal of $50 was recorded with a handwritten name that was not the resident's signature, and the initials next to it belonged to a former staff member. In another case, a $50 withdrawal was recorded with a cursive signature that the resident claimed was not theirs, as they typically sign with a scribble. The Business Office Manager confirmed that neither signature matched the residents' actual signatures. Additionally, the facility did not provide residents with ongoing access to their funds. One resident reported being unable to purchase cigarettes for about a month due to a lack of available petty cash, which was confirmed by the Activities Supervisor. The Business Office Manager admitted to asking residents to wait until the next day if cash was unavailable, and noted that there was no longer a receptionist with access to the office in the evenings. This situation had the potential to affect all residents for whom the facility managed funds.
Failure to Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to ensure safe smoking interventions for several residents, leading to unsupervised smoking activities. Residents who required supervision while smoking, as per their care plans, were observed smoking without staff supervision in the designated smoking area. This was contrary to the facility's policy, which mandates that all smoking must be supervised and that smoking materials should be stored by the staff. The facility's policy also specifies designated smoking times, which were not adhered to, as residents were found smoking outside these times. Resident #24, diagnosed with spina bifida, paraplegia, and bipolar disorder, was observed smoking unsupervised despite a care plan that required supervision and storage of smoking materials by the facility. The resident had a history of non-compliance with the smoking policy, including refusing to hand over smoking materials and smoking outside designated times. Similar issues were noted with Resident #48, who has cognitive loss and requires supervision, yet was found smoking unsupervised. The resident's care plan also indicated a need for supervision and storage of smoking materials by the facility. Other residents, including Resident #73, #76, and #80, also exhibited non-compliance with the smoking policy, smoking unsupervised and keeping smoking materials with them, contrary to their care plans. Interviews with staff and residents revealed that there were not enough staff to supervise smoking activities, and residents often obtained smoking materials from family members or during leaves of absence. The facility's failure to enforce its smoking policy and provide adequate supervision posed a risk to resident safety.
Sanitation Deficiencies in Food Storage and Distribution
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage and distribution of food, which could lead to cross-contamination and food-borne illness. Observations over several days revealed dirt and debris in the walk-in refrigerator and freezer, with food items not labeled or dated. The kitchen was found to have debris on shelves, counters, and floors, grime buildup on the commercial dishwasher, and a brown substance in the fryer. Additionally, there was carbon buildup on the convection oven doors, a black substance on the flat griddles, and grime on drinking cups. A plastic container labeled thickener lacked a use-by date. In the dry food storage room, there were dented cans of vegetable soup and apples, and an opened bag of powdered milk with a scoop in a dirty tub. Interviews with the Dietary Manager (DM) and the Administrator and Director of Nursing revealed expectations for food labeling, cleanliness of dishes, and maintenance of kitchen equipment, which were not met. The facility's policy required food to be procured from approved sources and stored, prepared, and served according to professional standards, which was not adhered to.
Inadequate Documentation and Communication in Dialysis Care
Penalty
Summary
The facility failed to provide adequate documentation and communication regarding dialysis care for a resident with end-stage renal disease, hypertension, and muscle weakness. The facility's policy required written communication between the dialysis provider and center staff, including daily weights, changes in condition, response to treatment, and evaluation of the vascular site. However, the review of the resident's medical record showed that 16 out of 31 opportunities for communication reports were missed, and vital signs were not documented after the resident returned from dialysis on three out of 15 occasions. Interviews with the resident and staff revealed inconsistencies in following the facility's dialysis care guidelines. The resident reported that staff did not consistently observe their arm for thrill and bruit, and the communication folder used for dialysis was not always utilized. Staff interviews indicated that the communication form was not consistently filled out or returned, and assessments were not always documented in the Treatment Administration Record. The facility's Administrator and Director of Nursing acknowledged the expectation for completed dialysis communication forms, highlighting a gap in adherence to the established protocol.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpsters were closed at all times and maintained to prevent pests and contain garbage. Observations were made on multiple occasions, showing the dumpster with its lid open and visible bags and miscellaneous items inside. These observations occurred on two consecutive days, with the dumpster lid found open at various times. Interviews with the Dietary Manager, Housekeeping and Laundry Manager, Administrator, and Director of Nursing revealed that they all expected staff to ensure the dumpster lids were closed after discarding trash. However, the facility did not provide a sanitation policy to guide these practices.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for a resident, as observed during a survey. The Licensed Practical Nurse (LPN) involved did not sanitize or wash hands before gathering supplies from the wound cart and placed soiled scissors on a clean barrier. The LPN used the same gloves to handle various items and did not change gloves between different wound care tasks. Additionally, the LPN used a soiled hand sanitizer bottle and did not wash hands after removing gloves or before leaving the resident's room. Interviews with the LPN and other staff, including the Infection Preventionist and Director of Nursing (DON), revealed a lack of adherence to the facility's infection control policies. The LPN admitted to using the same hand sanitizer and wound cleanser for multiple residents and acknowledged improper handling of soiled equipment. The Infection Preventionist and DON confirmed that staff should sanitize hands when entering and exiting rooms, change gloves between tasks, and clean shared equipment according to policy.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, specifically in controlling the fly population, which had the potential to affect all 83 residents. The facility's pest control policy, revised in September 2022, outlined measures to eradicate and control common household pests, including flies. However, a review of monthly pest control invoices from December 2023 to May 2024 showed no services targeting flies, despite the policy's requirement for comprehensive pest control services. Observations in various rooms and common areas revealed a significant presence of flies, with residents and staff noting the issue. Interviews with staff indicated that the change in pest control service providers led to a lack of communication and coordination in addressing the fly problem, as the new provider only sprayed a limited number of rooms per visit without a system to identify problem areas. Multiple observations documented flies in resident rooms, during wound care, in the dining room, and even during a resident council meeting. Staff interviews highlighted that the fly issue was exacerbated by residents opening windows and doors, particularly during seasonal changes. The Housekeeping and Laundry Manager noted that the previous system, which allowed staff to communicate pest control needs to the service provider, was no longer in place, leading to inadequate pest control measures. The Administrator and Director of Nursing acknowledged the expectation for the facility to be free from pests, yet the current pest control program was insufficient in addressing the fly infestation.
What surveyors are citing around you — mapped
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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 297 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marymount Manor | 9.6 mi | ★★★★★ | 1 | 0 |
| Pacific Care Center | 10.2 mi | ★★★★★ | 21 | 0 |
| St Andrew's At Francis Place | 10.5 mi | ★★★★★ | 2 | 0 |
| South County Health Care Center | 13.4 mi | ★★★★★ | 0 | 0 |
| Aegis Health And Rehabilitation | 13.7 mi | ★★★★★ | 1 | 0 |
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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.