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 Hilltop At Blue River, The during CMS and state inspections, most recent first.
A resident with a history of aggression struck another resident on the head with a dining room chair after an argument about talking to a person of the opposite sex. The injured resident, who had psychotic disorder with delusions and paranoid schizophrenia, sustained a scalp knot, a scratch on the nose, and head pain, while staff separated the two residents after both fell to the floor during the altercation.
A resident with multiple medical conditions and moderate cognitive impairment was forced out of bed by a CMT despite expressing a desire to remain in bed due to pain. The CMT disregarded the resident's refusal, used excessive force, and failed to notify the charge nurse as required. The incident was witnessed by an OTA and left the resident feeling uneasy and diminished.
A resident with moderate cognitive impairment and a diagnosis of dementia was admitted for rehab, but the facility failed to recognize and facilitate the financial POA's authority, instead redirecting the resident's social security income to a facility-controlled account and rejecting valid POA documentation, despite repeated attempts by the POA to clarify their role.
The facility consistently failed to provide adequate weekend nursing staff, resulting in repeated shortages of CNAs, CMTs, and nurses, as documented in staffing records and confirmed by staff interviews. A resident requiring two-person assistance with a mechanical lift reported frequent delays in care, including late transfers out of bed and missed or delayed meals. Staff described being unable to complete scheduled care tasks, such as bathing and feeding, due to insufficient staffing on weekends.
The facility did not use appropriate liquids or seasonings when preparing pureed carrots and chicken, resulting in bland and unappetizing meals for residents on pureed diets. Additionally, staff failed to monitor and maintain safe serving temperatures for foods such as carrots and ham, with some items served below the required temperature. These deficiencies were confirmed by both the cook and the Dietary Manager, who noted that recipes and temperature checks were not properly followed.
Surveyors found that kitchen equipment and surfaces, including the dishwasher, toaster, convection oven, well cookers, and floors, were not properly cleaned, with visible food debris and grease present. Dietary staff and the manager confirmed that cleaning protocols were not consistently followed, and deep cleaning was delayed, potentially affecting all residents receiving meals from the kitchen.
Two residents with dementia did not receive individualized, goal-directed activity plans that reflected their interests and abilities. Despite care plans specifying preferred activities and the need for one-to-one engagement, both residents were frequently left without meaningful activities, not invited to scheduled events, and lacked documented individualized interventions. Staff interviews and observations confirmed that activities were mostly group-based and not tailored to the residents' cognitive and physical needs.
A resident with cognitive impairment and hemiplegia was found smoking in their room and storing cigarettes and a lighter, despite facility policy requiring secure storage and supervised smoking in designated areas. Another resident from a secure unit accessed hazardous materials, including a board with nails and rocks, during a smoking break in an area near broken equipment, leading to a physical altercation and police intervention. Staff interviews revealed inconsistent supervision and lack of enforcement of smoking policies, resulting in unsafe conditions.
A resident with Alzheimer's disease and swallowing difficulties, who was at risk for weight loss, was not consistently served the physician-ordered pureed diet with large portions. Observations and staff interviews revealed that the resident often received regular portion sizes and non-pureed desserts, contrary to the diet card and care plan. Dietary and nursing staff did not consistently verify or communicate the correct diet orders, resulting in the resident not receiving the prescribed nutrition.
Several residents did not receive appropriate respiratory care due to missing or incomplete nebulizer equipment, improperly fitted CPAP masks, and unsanitary storage of oxygen and suction equipment. Residents with COPD and sleep apnea experienced delays in receiving necessary treatments, and oxygen delivery items were not maintained or stored according to facility policy, as evidenced by undated tubing, masks, and water jugs, and equipment placed directly on the floor.
A resident with significant dental issues, including only one remaining tooth and ongoing mouth pain, did not receive necessary dental care, extractions, or dentures despite repeated requests and staff awareness. Facility staff failed to document the dental needs, make appropriate referrals, or ensure dental appointments were scheduled, resulting in the resident not receiving routine or emergency dental services as required by policy.
A resident with a foot wound and recent IV antibiotic therapy did not have Enhanced Barrier Precautions (EBP) implemented as required, despite physician orders and facility policy. Staff provided high-contact care without gowns or gloves, and there was no EBP signage or PPE available at the resident's door until the issue was identified. Staff interviews revealed a lack of communication and awareness regarding the need for EBP for this resident.
A resident was found to have Melatonin and Tylenol stored in their room and was self-administering these medications without a physician order or documented assessment of their ability to do so. Staff were unaware of the medications' presence, and the required interdisciplinary evaluation and documentation for self-administration were not completed, contrary to facility policy.
Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse when one resident struck another resident on the head with a dining room chair during an altercation in the dining room. The injured resident had diagnoses including psychotic disorder with delusions, paranoid schizophrenia, anxiety disorder, and a right below-the-knee amputation. The other resident had diagnoses including dementia and diabetes and had a documented history of physical and verbal aggression toward residents and staff, with care plans noting a potential to demonstrate physical behaviors such as hitting, kicking, scratching, and grabbing. According to the investigation, the incident began when the aggressive resident approached the other resident about talking to a person of the opposite sex and stated that the behavior was adultery. The residents exchanged words, and the aggressive resident picked up a dining room chair and hit the other resident on the top of the head. The injured resident stood up when the chair was picked up, and both residents fell to the floor because they primarily ambulated by wheelchair due to poor gait. Staff separated the residents and returned them to their areas. The injured resident sustained a red and raised area on the head, a small scratch on the bridge of the nose, and a knot on the scalp, with pain rated as three out of ten. The resident refused hospital transfer and was treated in house. Staff interviews and progress notes showed differing accounts of the altercation, but both confirmed that the chair was used during the incident and that the residents were physically involved. Another resident later stated that the injured resident often said things that upset others and wanted that resident out of the facility.
Resident's Right to Dignity Violated by Forced Transfer from Bed
Penalty
Summary
A Certified Medication Technician (CMT) failed to honor a resident's right to self-determination and dignity by forcing the resident out of bed against their will. The resident, who had diagnoses including COPD, spondylosis, anemia, hyperlipidemia, and left-sided hemiplegia, was moderately cognitively impaired and reported increased leg pain on the day of the incident. Despite the resident's clear verbal refusal to get out of bed and participate in therapy, the CMT insisted, placed pants on the resident while they resisted, and physically moved the resident from a supine position to a wheelchair. An Occupational Therapist Assistant (OTA) witnessed the event and confirmed that the resident expressed a desire not to participate in therapy due to pain. The OTA observed the CMT using excessive force and commented on the roughness of the interaction. The resident later reported feeling uneasy and diminished by the experience, stating that the CMT spoke loudly and disregarded their wishes, which made them feel small and uncomfortable. During interviews, the CMT acknowledged being familiar with the facility's resident rights policy but admitted to not notifying the charge nurse when the resident refused to get out of bed. The CMT stated that they were concerned about medication administration and the resident's position but did not follow proper protocol for handling refusals. The Social Services Designee and the facility Administrator both confirmed that the resident's rights were not honored, and the incident was documented as a violation of the resident's right to dignity and choice.
Failure to Honor Resident's Power of Attorney for Financial Decisions
Penalty
Summary
The facility failed to ensure that a resident's designated power of attorney (POA) was able to exercise financial decision-making rights on behalf of the resident. The resident, who was moderately cognitively impaired with diagnoses including dementia and muscle wasting, was admitted to the facility for short-term rehabilitation. The admission agreement and facility policies recognized the rights of resident representatives to manage financial matters, but the facility did not properly acknowledge or facilitate the POA's authority during the resident's stay. Upon admission, the facility did not have documentation of the POA, despite the family member (Family Member A) presenting as the financial POA and being listed as such on the admission sheet. The facility staff claimed there was no family contact and no POA on file, and subsequently arranged for the resident's social security direct deposit to be changed to an account under facility control. This occurred even though the POA document, appointing Family Member A as attorney-in-fact for financial and legal matters, was drafted months prior and later presented to the facility. Communication between the family and facility staff revealed confusion and lack of recognition of the POA, with the Social Services Director rejecting the completed POA paperwork and requesting a new document. Interviews with facility staff indicated that there was difficulty contacting family members and uncertainty regarding the resident's capacity and wishes. The resident was described as providing conflicting information and expressing uncertainty about admission decisions. Despite the POA's attempts to clarify their status and manage the resident's finances, the facility proceeded with financial arrangements without proper involvement or consent from the POA, contrary to facility policy and the resident's rights.
Failure to Provide Sufficient Weekend Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends to meet the care needs of all residents, as evidenced by multiple documented staffing shortages across several months. Payroll Based Journal (PBJ) data submitted to CMS repeatedly triggered for excessively low weekend staffing, and daily staffing sheets from January through June 2024 showed frequent and significant shortfalls in the number of Certified Nursing Assistants (CNAs), Certified Medication Technicians (CMTs), and nurses scheduled for weekend shifts. On numerous occasions, the facility was short by several CNAs per shift, with some shifts missing as many as eight CNAs. There were also instances where documentation of staffing was missing entirely for certain days. Interviews with staff, including the Staffing Coordinator, CNAs, and a Registered Nurse, confirmed that the facility was regularly short-staffed on weekends. Staff reported being asked to work extra shifts, and managers sometimes worked on the floor, although there was no documentation to verify this. Staff described delays in resident care, such as assistance with getting out of bed, bathing, and feeding, particularly for residents requiring two-person assistance or mechanical lifts. The Director of Nursing (DON) was not aware of the PBJ staffing triggers and did not monitor PBJ reports, relying instead on the Staffing Coordinator to notify them of shortages. There was no documentation of managerial assistance with nursing tasks during shortages. One resident with a history of traumatic brain injury, lack of coordination, heart failure, and muscle weakness, who required a mechanical lift and two staff for transfers, reported that on many weekends there was not enough staff to assist with getting out of bed in a timely manner. The resident stated that they often remained in bed until the afternoon, missing breakfast, and that meals were sometimes served late when staffing was insufficient. Staff interviews corroborated that care tasks, including scheduled baths and timely transfers, were delayed or missed due to inadequate staffing on weekends.
Failure to Ensure Palatable Pureed Foods and Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain the nutritive value and palatability of pureed foods for residents on pureed diets, as well as to ensure that food was served at safe and appetizing temperatures. During meal preparation and service, pureed carrots and pureed chicken were prepared using only water as the liquid, rather than broth, chicken base, or milk as specified in the facility's recipes. Both the cook and the Dietary Manager confirmed that the pureed foods were bland, lacked seasoning, and did not taste like the intended food items. The cook was unaware of the requirement to use broth or other flavor-enhancing liquids and had not reviewed the recipe prior to preparation. Additionally, the facility did not consistently monitor or record food temperatures before serving. Observations showed that the temperatures of certain food items, such as carrots and ham, were below the acceptable serving temperature, with ham slices measured at 104°F and carrots at 111°F. The Dietary Manager acknowledged that food temperatures were not taken before service on the day in question, contrary to facility policy. These failures potentially affected all residents receiving pureed diets and those consuming food outside the kitchen.
Failure to Maintain Kitchen Cleanliness and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple instances of uncleanliness and food debris in the facility's kitchen, including yellowish, dried food debris on the outside of the dishwasher, spilled cereal debris on and around a tray and the floor, and a toaster with dried food debris and grease on both the exterior and internal roller mechanism. The convection oven was found with baked-on grease and debris on the knobs, panel, front, and sides, as well as thick, greasy debris on the top and backsplash. The well cookers had dried food debris on the outside, and the kitchen floor throughout was soiled with food debris and stains that appeared to have accumulated over time. Interviews with dietary staff and the Dietary Manager confirmed that cleaning protocols were not consistently followed. Staff acknowledged that equipment such as the wells, toaster, and stove were not being cleaned as required after each meal or on a weekly deep-cleaning schedule. The Dietary Manager also noted that the floors were dirty and awaiting cleaning by an outside vendor, while dietary staff were only sweeping and mopping at the end of the day. These lapses in cleaning and maintenance potentially affected all residents who consumed food prepared in the kitchen, with a facility census of 140 residents.
Failure to Provide Individualized Activity Plans for Residents with Dementia
Penalty
Summary
The facility failed to ensure individualized, goal-directed activity plans that incorporated the interests and abilities of two residents with dementia. Both residents had documented cognitive impairments and required varying levels of assistance with daily activities. Despite care plans outlining specific preferences and interventions, such as enjoyment of music, church services, socializing, and outdoor activities, observations and interviews revealed that these preferences were not consistently addressed or implemented in daily programming. For one resident with Alzheimer's disease, hemiplegia, and significant memory loss, the care plan included a variety of preferred activities and required one-to-one or in-room activities when unable to attend group events. However, observations showed the resident was often left in common areas without engagement, not invited to scheduled activities, and did not receive documented one-to-one activities as required. Staff interviews confirmed a lack of individualized engagement, with most activities being group-based and little evidence of tailored interventions for the resident's cognitive and physical limitations. The second resident, diagnosed with dementia and agitation, was noted to have a strong preference for music, animals, outdoor activities, and group participation. Despite this, the resident was frequently observed wandering the unit without engagement in activities, and staff primarily redirected the resident or provided snacks rather than meaningful activity involvement. Documentation of one-to-one activities was minimal, and staff interviews indicated that such individualized activities were rarely provided. Activity staff and CNAs acknowledged the challenges in engaging the resident but did not consistently implement or document individualized interventions as outlined in the care plan.
Failure to Prevent Smoking Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to resident smoking practices and supervision. One resident with a history of stroke, hemiplegia, and moderate cognitive impairment was found to have smoking materials, including cigarettes and a lighter, in their room and admitted to smoking in the restroom, contrary to facility policy. The resident was aware of the rules prohibiting smoking and storage of smoking materials in resident rooms, and staff confirmed that the resident had previously been found smoking in their room. Despite the facility's policy requiring smoking materials to be stored securely by staff and only used in designated areas under supervision, both the resident and their roommate had smoking materials in their room, and there was no documentation of progressive disciplinary action as outlined in the facility's policy. Another resident, who resided on a secure unit due to dementia and other psychiatric diagnoses, was involved in an incident during a supervised smoking break. The resident obtained a 2x4 board with nails, rocks, and other potentially hazardous items from the area near the designated smoking section, which was located close to a maintenance garage with broken equipment and accessible debris. The resident attempted to bring the board into the building, became physically aggressive, and required intervention from staff and police. Observations confirmed that the smoking area was not fenced off and that residents could access hazardous materials, with staff and maintenance acknowledging that residents were able to wander away from the designated area and obtain dangerous items during smoking breaks. Interviews with staff, including CNAs, RNs, and the DON, revealed inconsistent supervision during smoking breaks and a lack of awareness regarding residents' movements and access to hazards. Staff reported that hospitality aides were responsible for monitoring residents from the locked unit during smoking breaks, but there was evidence that residents were able to leave the designated area unsupervised. Maintenance staff also noted that hazardous materials were accessible and that they had previously found rocks in resident rooms. The facility's failure to enforce its smoking policy, supervise residents adequately, and maintain a hazard-free smoking area resulted in unsafe conditions for residents.
Failure to Provide Physician-Ordered Diet Texture and Portion Size
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, hemiplegia, muscle wasting, and a cognitive communication deficit, who was at risk for weight loss, did not receive the physician-ordered pureed diet with large portions as specified on the resident's diet card. Observations on multiple occasions showed the resident was served regular portion sizes instead of large portions, and was also given a regular dessert instead of a pureed dessert. The resident's care plan and physician's orders clearly indicated the need for a pureed diet with large portions, but these instructions were not consistently followed by dietary staff. Certified Nursing Assistants (CNAs) and the Dietary Manager confirmed that the resident was supposed to receive large portions and pureed desserts, but this was not routinely provided. CNAs reported that the dietary staff rarely served large portions and did not always check the diet cards for accuracy. On one occasion, a CNA had to page dietary staff to correct the dessert and portion size after noticing the error. The Dietary Manager acknowledged the mistake and stated that the kitchen staff should have followed the diet card instructions. The Director of Nursing (DON) stated that the expectation was for the resident's physician-ordered diet to be followed and for nursing staff to document meal consumption and any concerns about the resident's diet order. However, the DON was not made aware of the resident not receiving the correct diet until after the deficiency was identified. The lack of adherence to the prescribed diet and portion size for the resident with significant health concerns led to the deficiency.
Deficiencies in Respiratory Care Equipment Provision and Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in the provision and maintenance of respiratory equipment. One resident with a diagnosis of COPD did not have access to a complete nebulizer setup for several days, despite having a physician's order for nebulizer treatments. The resident repeatedly requested the missing mouthpiece and tubing after being moved to a new room, but staff did not provide the necessary components or a replacement nebulizer until several days later. Observations confirmed the absence of the required parts, and interviews with the resident and roommate corroborated that the equipment was incomplete and requests for assistance were not addressed in a timely manner. Another resident with obstructive sleep apnea was observed multiple times sleeping with a CPAP mask that was not properly fitted, resulting in oxygen leaking from the sides of the mask. The resident reported difficulty keeping the mask on due to facial hair and stated that the CPAP mask and nebulizer mouthpiece had never been cleaned. Staff interviews indicated awareness of the challenges with mask placement but did not document any interventions to ensure the mask was correctly positioned or that the equipment was maintained according to policy. Additionally, two residents with respiratory conditions had oxygen and suction equipment that was not stored in a sanitary manner. Observations revealed that oxygen tubing, masks, and suction machine tubing were not dated to indicate when they had last been changed, and equipment such as humidifier water jugs and suction machines were stored directly on the floor and not in protective bags. These practices were inconsistent with the facility's own policies, which require weekly changes of oxygen delivery items, proper storage in clean, dry places, and dating of equipment to ensure timely replacement.
Failure to Provide Required Dental Care and Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental care, including both routine and emergency services, as required by facility policy. The resident, who had a history of severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency, was observed to have only one remaining tooth and reported ongoing mouth pain and difficulty eating. Despite the resident's requests to have the remaining tooth and broken fragments extracted and to be fitted for dentures, there was no documentation of dental services being provided, no dental appointments scheduled, and no orders for dental care in the resident's medical record. Staff interviews revealed that certified nursing assistants were aware of the resident's dental issues and difficulties with eating, but had not communicated these concerns to nursing staff. The registered nurse interviewed was unaware of the resident's dental condition and confirmed that there was no documentation or orders for dental care. The director of nursing acknowledged that the resident should have been assessed for dental needs upon admission, and that missing teeth should have been documented and addressed in the care plan, but this was not done. Facility policy required oral assessments upon admission and as needed, documentation of adverse oral conditions, and referral for dental services, including arranging appointments and transportation. However, the resident's care plan and assessments did not address the broken or missing teeth, and the resident had not seen a dentist in over a year. The lack of follow-through on dental referrals and absence of documentation resulted in the resident not receiving the necessary dental care, including extractions and dentures, as requested and indicated by their condition.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound and IV Therapy
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a foot wound and recent intravenous (IV) antibiotic therapy, as required by their infection prevention and control program. The resident had a history of stroke with paralysis, diabetes, peripheral vascular disease, and was totally dependent on staff for all activities of daily living. The care plan and physician's orders indicated the need for EBP, including the use of gowns and gloves during high-contact care activities due to the presence of a vascular wound and recent IV access. Despite these documented requirements, multiple observations over several days revealed that there was no EBP signage or personal protective equipment (PPE) available at the resident's door. Staff, including CNAs, were observed providing direct care such as repositioning, checking for incontinence, and changing linens without wearing gowns or gloves. Interviews with staff confirmed a lack of awareness that the resident required EBP, and that no communication had occurred to inform them of the need for these precautions. Staff also reported that EBP signage and PPE were typically used for residents with wounds or medical devices, but in this case, these measures were not in place until after the deficiency was identified. The Director of Nursing confirmed that the protocol required assessment and implementation of EBP, including signage and PPE, for residents with wounds or devices. However, the EBP was not in place for this resident until it was brought to the attention of the facility, despite the resident having a wound and recent IV therapy. The lack of EBP implementation was due to a failure in communication and adherence to established infection control protocols.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician order for self-administration of medication at bedside and did not evaluate or document a resident's ability to self-administer medication. One resident, who was cognitively intact and had diagnoses including insomnia, scoliosis, and spondylosis, was found to have bottles of Melatonin and Tylenol stored in the bottom drawer of their nightstand. The resident reported that their family had provided the medications and that staff were unaware of their presence. The resident had been taking the Tylenol for pain and Melatonin for sleep, including doses from both their own supply and what was provided by the facility. Staff interviews revealed that medication technicians and nurses were not aware that the resident had medications in their room, and there was no current order or assessment permitting self-administration. The facility's policy required an interdisciplinary assessment and a physician order before allowing residents to self-administer medications or store them at bedside, but this process was not followed for the resident in question. Staff also indicated that medications had previously been found and removed from the resident's room, but no formal assessment or documentation was completed. The Director of Nursing and other staff confirmed that the resident did not have an order or assessment for self-administration and that the presence of medications in the resident's room was not known until it was brought to their attention. The psychiatric nurse practitioner stated that no resident should have medications at bedside without an assessment, and expected staff to supervise all medication administration. The facility census at the time was 137 residents, and this deficiency was identified for one sampled resident out of twelve reviewed.
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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 Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgewood Health Care Center | 1.7 mi | ★★★★★ | 28 | 3 |
| Kingswood Senior Living | 2.1 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Carondelet Llc | 2.3 mi | ★★★★★ | 34 | 0 |
| Hope Care Center | 3.3 mi | ★★★★★ | 14 | 0 |
| Life Care Center Of Grandview | 3.3 mi | ★★★★★ | 23 | 0 |
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