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 Beautiful Savior Home during CMS and state inspections, most recent first.
Resident-to-resident altercation with jaw/neck grabbing and injury. Two residents became stuck while passing in a hallway, and after one resident made contact with the other’s arm, the second resident grabbed the first resident’s jaw/neck area and shook the resident. Staff documented discoloration and bruising to the resident’s upper neck/jaw area, and witness accounts described the grip as tight and choking/grabbing in nature.
A resident with dementia and severe cognitive impairment struck another resident in the face with a fist after the other resident approached in close proximity at the nurse’s station. Staff heard the altercation, observed the injured resident holding the face with redness and later bruising, and the incident was documented as resident-to-resident aggression. Facility leadership and the psychiatrist NP did not consider the event abuse, describing it as an unintentional reaction related to the aggressor’s cognitive impairment.
The facility failed to ensure the Dietary Manager met the necessary qualifications, as the current DM lacked certification or education for the role. The DM had been in the position for two months without the required training, following the sudden departure of the previous manager. This deficiency potentially affected all 76 residents.
The facility failed to maintain sanitary conditions in the kitchen, with improper storage and cleanliness of condiments, spices, and surfaces. Observations revealed greasy and dusty kitchen appliances, improperly stored condiments, and incomplete cleaning tasks. Interviews with dietary staff highlighted a lack of adherence to cleaning protocols, contributing to unsanitary conditions.
The facility failed to follow infection control practices, including inadequate hand hygiene and PPE use for residents on Enhanced Barrier Precautions. Staff did not use gowns or wash hands properly during care, and TB testing was not completed annually for some residents. These lapses were acknowledged by staff and confirmed by the DON.
The facility failed to designate CPR-certified staff and CPR teams on staffing sheets, as required by policy. Interviews with staff, including a Nurse's Aide, Housekeeping Supervisor, and Director of Nursing, confirmed the absence of such designations, potentially delaying CPR initiation during emergencies.
The facility failed to implement an antibiotic stewardship program from September to November 2024 due to management changes. The DON and Infection Preventionist did not gather or analyze data, and the administrator was unaware of the lapse.
A resident with Parkinson's disease requiring substantial assistance for bathing did not receive regular baths as per their care plan. Documentation showed significant gaps in bathing over several months, with the resident reporting infrequent baths despite requests for assistance. Facility staff were unaware of the missed baths, indicating a disconnect between expected and actual care.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident with a chronic Stage IV ulcer did not receive consistent weekly wound assessments, while another high-risk resident did not have heel protectors applied despite redness and risk of skin breakdown. Staff interviews revealed a lack of awareness and communication regarding necessary interventions.
A facility failed to conduct thorough fall investigations and implement suitable interventions for a cognitively impaired resident with a history of falls. Despite multiple falls, some resulting in injuries, the facility did not complete fall assessments or update care plans with appropriate interventions. Staff interviews revealed that the interventions used were inappropriate for the resident's memory loss, and the DON admitted that not all fall investigations were completed per policy.
A facility failed to accurately assess a resident's PEG tube placement, as staff did not measure the external length of the tube, despite the resident's care plan requiring checks for tube placement and gastric residual. The LPN followed facility policy by auscultation and aspiration but did not measure the tube, and the DON confirmed that orders did not include this step.
Resident-to-Resident Altercation Resulting in Jaw/Neck Grabbing and Injury
Penalty
Summary
The facility failed to ensure a resident was free from abuse when another resident forcefully grabbed the resident’s chin/jaw area during a hallway altercation, causing discoloration and bruising to the upper neck/jaw area. The incident involved two residents passing each other in a hallway while seated in wheelchairs, and both residents became stuck while trying to move past one another. One resident was observed raising an open hand that contacted the other resident’s forearm, after which the second resident reached out and made contact with the first resident’s upper neck/jaw area in a tight gripping, choking, and grabbing manner. The resident who was grabbed had a history of hemiplegia and hemiparesis following a cerebrovascular accident and had moderately impaired cognition on the most recent quarterly MDS. The other resident was cognitively intact and had no behavioral symptoms documented in the seven-day look-back period on the annual MDS. Staff documentation described the interaction as a resident-to-resident altercation that escalated after the residents became too close while passing in the hallway. The incident report and nursing notes stated that the second resident continued attempting to pass, the residents became stuck, and the second resident then grabbed and shook the first resident’s head while staff attempted verbal redirection. Witness statements and interviews showed differing interpretations of the event, but multiple staff accounts described the second resident intentionally gripping the first resident’s jaw/neck area and not letting go immediately when told to stop. The injured resident stated that the other resident grabbed the jaw forcefully, attempted to grab the neck, and caused pain and bruising, and later stated that the incident felt like physical abuse. The administrator and DON stated they did not consider the event abuse and viewed it as a behavioral escalation after the residents both tried to pass in the hallway at the same time.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse for one resident when another resident struck him/her in the face with a fist. On 4/26/26, Resident #1 was sitting in a wheelchair at the nurse’s station with other residents nearby when Resident #2 rolled up in a wheelchair and was in close proximity. Staff heard Resident #2 yell out and then observed Resident #2 holding the left side of the face while Resident #1 had a balled fist and stated that he/she punched Resident #2 because Resident #2 was “running their mouth,” adding that he/she enjoyed it. Staff separated the residents after the incident. Resident #1 had diagnoses including dementia, anxiety disorder, traumatic brain injury, and unsteadiness on feet, and was documented as severely cognitively impaired with potential and actual verbal and physical aggression toward staff and others. Resident #2 had vascular dementia with agitation, restlessness and agitation, memory deficit from a stroke, and was documented as moderately cognitively impaired. The incident investigation noted that Resident #1 was alert and oriented only to self and Resident #2 was alert and oriented to self. The investigation also documented discoloration to Resident #2’s lower left lip area, with staff later noting redness and bruising that developed after the incident. Staff interviews described hearing the hit and seeing Resident #2 holding the face immediately afterward. The facility’s own records and interviews reflected that the event involved resident-to-resident aggression, yet the incident was later characterized by facility leadership and the psychiatrist NP as not being abuse and as an unintentional reaction related to Resident #1’s dementia and cognitive impairment.
Dietary Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the necessary qualifications for the position, as outlined in their policy. The DM, who had been in the role for two months following the abrupt departure of the previous manager, lacked any certification or education required for the position. The DM had prior experience as a kitchen supervisor but had not worked as a DM before and had not received any training to meet the qualifications. This deficiency potentially affected all 76 residents of the facility. The facility's policy required that if a dietitian is not employed full-time, a Director of Food and Nutrition Services must be designated with specific qualifications. These include being a certified dietary manager, having an associate degree in food service management, or having two or more years of experience in a similar role in a nursing facility setting, along with completing a course in food safety and management. The current DM did not meet any of these criteria, and the facility administrator acknowledged the lack of appropriate qualifications and training for the DM.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain proper storage and cleanliness standards for condiments, spices, and kitchen surfaces, as observed during multiple inspections. Condiments such as syrup, mustard, ketchup, and grape jelly were found improperly stored, with open lids and without refrigeration where required. Spice containers were greasy, with open lids exposing contents to dust and debris. The kitchen surfaces, including the stove, oven, and microwave, were observed with significant grease build-up, and the gas lines behind these appliances were coated with grease and dust. The facility's cleaning practices were inadequate, as evidenced by the condition of the kitchen floors, which were dirty and covered with debris. The bottom shelves of the microwave table and food prep tables were chipped and stained, making them unsanitary for storing trays and food containers. The dishwashing trays were coated with a charcoal/mold-like substance, and the wall behind the steam table was dirty with dust. The facility's cleaning checklists from July to December 2024 showed numerous tasks left incomplete, with many monthly and daily cleaning tasks not dated or initialed as completed. Interviews with dietary staff revealed a lack of adherence to cleaning protocols and schedules. Staff admitted to leaving condiments out and not cleaning condiment containers, floors, or kitchen surfaces regularly. The Dietary Manager acknowledged the need for refrigeration of certain condiments and the requirement for regular cleaning of spice containers and kitchen surfaces. Despite having a cleaning schedule, tasks were often left undone, and maintenance issues, such as missing floor tiles, were not addressed, contributing to the unsanitary conditions observed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices for several residents, leading to deficiencies in care. For one resident on Enhanced Barrier Precautions (EBP), Certified Nursing Assistants (CNAs) did not use personal protective equipment (PPE) such as gowns and failed to perform adequate hand hygiene during incontinence care. The CNAs did not wash their hands before applying gloves, did not cleanse the resident's front genitalia, and did not change gloves or wash hands after handling soiled materials. This lack of adherence to EBP protocols was acknowledged by the CNA involved, who admitted to not noticing the EBP signage and not being informed by the charge nurse. Another resident with an indwelling catheter did not have appropriate EBP signage or PPE cart outside their room, leading staff to handle the catheter bag without using PPE. Similarly, a resident with a PEG tube did not receive care with the required PPE, and the LPN involved failed to perform hand hygiene between glove changes and contaminated clean supplies by touching them with dirty gloves. The LPN admitted to not following proper procedures and acknowledged the need for gown use during PEG tube care. Additionally, the facility did not complete annual tuberculosis (TB) testing for two residents, with the last recorded tests being several years overdue. The Director of Nursing (DON) confirmed the expectation for annual TB testing but could not locate recent records. These deficiencies highlight lapses in infection control practices, including hand hygiene, use of PPE, and adherence to TB testing protocols, which are critical for preventing the spread of infections in the facility.
Lack of CPR Certification Designation on Staffing Sheets
Penalty
Summary
The facility failed to implement a process to ensure that staff members who were CPR certified were identified on all shifts. The facility's policy required a designated CPR team for each shift, including a team leader, to coordinate rescue efforts in the event of a cardiac arrest. However, a review of the facility's staffing sheets revealed that there was no designation for CPR-certified employees, the CPR team, or the CPR team leader on any of the reviewed dates. Interviews with various staff members, including a Nurse's Aide, Housekeeping Supervisor, Staffing Coordinator, Certified Nurses Aide, Certified Medication Technician, and Licensed Practical Nurse, confirmed the absence of such designations on the staffing sheets. The Director of Nursing acknowledged that the daily staffing schedule did not indicate who was CPR certified or who was part of the CPR team, which could potentially delay the initiation of CPR in an emergency. The Director of Nursing and the Staffing Coordinator were identified as responsible for maintaining a list of CPR-certified staff and ensuring it was available at the nurse's station. This deficiency highlights a lack of preparedness in responding to cardiac emergencies, as staff would need to inquire about CPR certification during a critical situation, potentially delaying life-saving interventions.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship protocol and a system to monitor appropriate antibiotic use for its residents. The facility's Antibiotic Stewardship policy, revised in December 2023, outlined that antibiotics should be prescribed and administered under the guidance of the facility's program, with specific instructions for physician orders. Additionally, the Infection Prevention and Control Program policy required culture reports, sensitivity data, and antibiotic usage reviews to be part of surveillance activities. However, from September 2024 through November 2024, no information was provided regarding antibiotic stewardship, indicating a lapse in the program's implementation. Interviews with the Director of Nursing (DON) and the Infection Preventionist revealed that antibiotic stewardship data was not gathered or analyzed for the months of September through November 2024 due to management activities and system changes related to new ownership. The DON acknowledged responsibility for ensuring monthly completion of antibiotic stewardship, while the Infection Preventionist confirmed the lack of completion during the specified period. The facility's administrator was unaware of the deficiency, indicating a communication gap within the facility's management team.
Failure to Provide Regular Bathing Assistance to Resident
Penalty
Summary
The facility failed to ensure that Resident #68, who required substantial assistance with bathing due to Parkinson's disease, received regular baths or showers. The resident's care plan and Minimum Data Set indicated a need for significant staff assistance with bathing. However, documentation revealed that the resident received only sporadic baths over several months, with significant gaps where no baths were documented. For instance, the resident went without a bath for 13 consecutive days in September, 28 consecutive days in November, and had no documented baths in December. Observations noted the resident had a body odor and greasy hair, and the resident reported not receiving baths twice a week as expected, even after requesting assistance. Interviews with facility staff, including nursing assistants, LPNs, the Assistant Director of Nursing, and the Director of Nursing, revealed a lack of awareness regarding the resident's missed baths. Staff were under the impression that baths were being offered twice a week, as per facility policy, and documented accordingly. However, there was a disconnect between the expected and actual care provided, as staff did not notice any odors or unkempt appearances, and the charge nurses were responsible for scheduling and ensuring baths were completed. The facility's failure to adhere to its bathing schedule and documentation procedures resulted in the resident not receiving the necessary personal hygiene care.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to ensure proper weekly wound tracking and care for a resident with a chronic Stage IV pressure ulcer. The resident, who was cognitively intact, had a history of a Stage IV pressure ulcer in the sacral area that would frequently heal and reopen. Despite the physician's order for weekly skin assessments, there were multiple instances where detailed wound assessments were not documented. This lack of documentation spanned several months, indicating a failure in maintaining consistent wound care and monitoring. Another resident, who was at high risk for skin breakdown due to flaccid hemiplegia and incontinence, did not receive adequate preventive measures for pressure ulcers. Observations showed that the resident's heels were consistently resting directly on the mattress, despite being identified as high risk for pressure ulcers. Although heel protectors were ordered after redness was noticed on the resident's heels, they were not applied, and the staff was unaware of the need for these interventions. Interviews with various staff members, including CNAs, LPNs, and the DON, revealed a lack of awareness and communication regarding the necessary interventions for residents at high risk for pressure ulcers. The facility's failure to implement and document appropriate preventive measures and wound care assessments contributed to the deficiencies identified in the care of these residents.
Inadequate Fall Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct thorough fall investigations and implement appropriate interventions for a significantly cognitively impaired resident. The resident, who had a history of dementia and delusional disorder, experienced multiple falls, some resulting in injuries. Despite these incidents, the facility did not complete fall assessments after each fall, nor did they update the resident's care plan with new interventions. The interventions that were implemented, such as reminding the resident to use the call light, were not suitable given the resident's cognitive impairments. The facility's policy on assessing falls and their causes was not followed, as evidenced by the lack of staff interviews or root cause analyses in the fall investigations. The resident's fall risk assessments were incomplete, lacking total scores and suggested interventions. Additionally, new fall risk assessments were not conducted after the resident's falls on specific dates, indicating a failure to reassess the resident's fall risk and adjust care plans accordingly. Interviews with facility staff, including nursing assistants, LPNs, the ADON, and the DON, revealed a consensus that the interventions used were inappropriate for a resident with memory loss. The DON acknowledged that not all fall investigations were completed per facility policy, highlighting a systemic issue in the facility's approach to fall management and prevention.
Failure to Accurately Assess PEG Tube Placement
Penalty
Summary
The facility failed to accurately assess the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube for a resident, leading to a deficiency in care. The resident, who was admitted with moderate cognitive impairment and received over 51% of their nutrition through tube feeding, had a care plan that required staff to check the PEG tube placement and gastric residual. However, the care plan did not specify checking the PEG tube by measurement. During an observation, an LPN administered an air bolus and listened for sound through the resident's abdomen, aspirated for gastric contents, and flushed the PEG tube with water, but did not check the external length or measurement of the PEG tube. Interviews with the LPN and the Director of Nursing (DON) revealed that staff were instructed to verify PEG tube placement by auscultation and aspiration of gastric contents, following the facility's policy. However, the facility's policy and the physician's orders did not include measuring the tube to check for placement. The LPN admitted to never measuring a resident's external PEG tube length and did not recall seeing documentation of the external length in residents' charts. The DON confirmed that the orders did not include measuring the tube for placement, which contributed to the deficiency in accurately assessing the resident's PEG tube placement.
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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.
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Nursing homes near Belton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carnegie Village Rehabilitation & Health Care Cent | 1.2 mi | ★★★★★ | 0 | 0 |
| Foxwood Springs Living Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Sunrise Nursing & Rehabilitation | 4.6 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Grandview | 6.9 mi | ★★★★★ | 23 | 0 |
| The Healthcare Resort Of Leawood - Iron Horse Hlth | 8 mi | ★★★★★ | 5 | 1 |
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