Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pinnacle Point Wellness & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Failure to Maintain Resident Dignity and Respond to Requests: Staff allowed a resident with severe cognitive impairment and a history of verbal aggression to yell obscenities and threatening statements in common areas while another resident with dementia remained in the dining room and complained about the ongoing disruption. Staff did not explain the behavior, intervene to protect other residents, or redirect the resident as directed by the care plan. Staff also walked past two residents who repeatedly used the call light and asked for a snack, did not acknowledge them, and later brought only drinks, leaving the residents feeling disrespected.
Failure to Obtain Consent Before Starting Psychotropic Medications: The facility did not obtain consent from residents or their representatives before starting psychotropic medications for four residents. Records showed antidepressant, anti-anxiety, and other related meds were initiated before consent was documented, and facility leaders stated nursing, social services, or administration were responsible for obtaining consent before these meds were started.
Failure to use required PPE during resident care. Staff did not follow standard precautions and EBP for two residents. An LPN administered insulin to a resident with dementia and diabetes without gloves, and another LPN performed tube feeding for a resident with severe cognitive impairment and a feeding tube without wearing a gown during high-contact care, despite EBP signage and supplies being available.
The facility failed to accommodate the needs of a non-English speaking resident by not providing consistent communication aids, leaving the resident without engagement in their primary language. Additionally, another resident was not provided appropriate seating during meals, making self-feeding difficult. Staff were not adequately trained on using communication tools, and recommendations for alternative seating were not implemented.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents at least two days before the end of their Medicare Part A stay. The NOMNC was issued and signed on the last day of coverage for both residents. Interviews revealed that the Business Office Manager and Administrator were unaware of the proper procedure and timeline for issuing the NOMNC, leading to non-compliance with CMS guidelines.
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents. A resident with cognitive loss was distressed by a continuously beeping door alarm, while another resident with anxiety and depression was disturbed by a loud clunking noise from a broken smoking cart wheel. The facility also had multiple unclean and damaged areas, with ineffective housekeeping and maintenance practices. The lack of a sound level policy and delayed corrective actions contributed to these deficiencies.
The facility failed to ensure residents were free from physical restraints, as evidenced by the improper use of a seat belt for a resident with severe cognitive impairment and locked wheelchair brakes for another resident with significant cognitive loss. The facility did not have necessary physician orders, assessments, or care plans for these restraints, leading to inappropriate restriction of residents' freedom of movement.
The facility did not conduct timely FCSR background checks for a Dietary Aide, an LPN, and a CNA before they interacted with residents, contrary to its Abuse Prevention Policy. The Human Resources Manager and Administrator acknowledged the oversight, which allowed these employees to have contact with residents without the required pre-screening.
The facility failed to complete accurate and timely MDS assessments for several residents. A resident was discharged without a discharge MDS, another had no MDS updates for months, a third passed away without a final MDS, and a fourth's MDS did not reflect dialysis treatment. Staff interviews revealed issues with obtaining RN signatures and unawareness of unsubmitted assessments.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical areas such as BIPAP machine use, side rail usage, and significant weight loss. A resident's care plan did not include BIPAP use despite respiratory conditions, and side rails were used without documentation. Another resident's care plan lacked side rail documentation, despite their use for repositioning. Two residents experienced significant weight loss without care plan interventions. Staff interviews revealed a lack of awareness and updates in care plans.
Two residents in a facility, both dependent on staff for ADLs and always incontinent, did not receive necessary perineal care every two hours as required. Observations showed staff failed to reposition or assess the need for care over several hours, despite strong urine odors indicating neglect. Interviews with CNAs confirmed the lack of care, and care plans did not address routine incontinent care, leading to deficiencies in maintaining residents' personal hygiene.
The facility failed to address significant weight loss and provide adequate hydration for several residents. One resident experienced a 13.56% weight loss over six months without a care plan or interventions. Another resident lost 15.34% of their body weight over three months, with no specific interventions documented. Observations showed a lack of fluids and snacks, and inconsistent assistance during meals. Staff interviews revealed discrepancies in hydration procedures, contributing to these deficiencies.
The facility failed to assess bed rail entrapment risks for four residents, leading to the installation of side rails without proper evaluation or physician's orders. Residents had various medical conditions requiring careful consideration before using bed rails. The facility lacked a policy on entrapment, and entrapment evaluations were incomplete.
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included improper blood sugar testing procedures for multiple residents, incorrect application and removal of pain patches, and delayed meal service after insulin administration. These deficiencies affected the care of several residents, highlighting issues in medication management and adherence to physician orders.
Two residents experienced issues with the palatability and attractiveness of their meals. One resident with severe cognitive impairment struggled with dry rice, while another with moderate cognitive impairment and a history of stroke was served disliked rice and dry chicken. The facility lacked a policy for resident food preferences, and the Dietary Manager was unaware of complaints.
The facility was found to have multiple maintenance issues, including dust, debris, and mold-like substances in various areas, chipped paint, and rusted frames. Interviews revealed unclear responsibilities between housekeeping and maintenance staff, and no written plan for repairs. The administrator expected the building to be clean and in good repair.
The facility failed to maintain an effective pest control program, leading to the presence of gnats, flies, and wasps in resident rooms, dining areas, and hallways. Observations revealed multiple instances of pests, including flies landing on a resident and crawling on their bed. The facility lacked a pest control policy, and pest control services were limited to outside fly control. The Administrator acknowledged the issue and stated that pest control would be notified.
A resident with dementia and anxiety was treated without dignity when a CNA shook their shirt despite requests to stop, and an LPN restricted their movement by yelling at them for self-propelling their wheelchair. The facility's actions disregarded the resident's rights to a dignified existence and self-determination.
A resident with bilateral sensorineural hearing loss did not receive assistance from the facility in obtaining a hearing aid. The care plan lacked documentation of the resident's hearing needs, and there was confusion among staff about responsibilities. The Social Services Director and transportation person did not document or follow up effectively, leading to delays in obtaining the hearing aid.
A significant medication error occurred when a resident did not receive a meal within the required time after receiving fast-acting insulin. The resident's blood sugar was checked, and 4 units of Humalog insulin were administered, but the meal was delayed by nearly an hour, contrary to the manufacturer's guidelines. The LPN assumed the resident had gone to the dining room, but the resident remained in their room and expressed hunger. The DON confirmed that the insulin should be given no earlier than 10 minutes before a meal.
The facility failed to complete performance reviews of CNAs at least once every 12 months and did not provide regular in-service education based on the outcome of the reviews. A review of 52 CNA personnel files revealed this deficiency, and the Executive Director admitted to not having the necessary competency evaluations.
The facility failed to ensure proper food safety and hygiene practices, including unsealed food in the freezer, dirty containers, dusty shelving, and a dietary cook not performing hand hygiene while handling food and equipment.
The facility failed to have a written transfer agreement with a hospital to ensure timely hospital admission and information exchange for residents. The Executive Director was unaware of the Federal requirement and believed it was not necessary in Missouri. She had never seen a written transfer agreement at the facility and stated she would begin the process of obtaining one.
The facility failed to implement and maintain their infection prevention and control program, resulting in a lack of documentation and tracking of infections. The Infection Preventionist, new to the position, acknowledged the deficiencies, and the Corporate Nurse confirmed the need for improvement towards compliance with IPCP regulations.
The facility failed to ensure residents who smoked were assessed and supervised according to their needs. Several residents were observed smoking unsupervised outside designated areas, and the facility did not have a system to identify and monitor residents' smoking needs. Additionally, care plans and smoking evaluation tools were incomplete or missing for some residents.
The facility failed to ensure timely administration and availability of prescribed medications for eight residents, resulting in a medication error rate of 49.15%. Issues included assumptions about resident refusals, delays in administration, and failure to reorder medications on time.
The facility failed to implement and maintain their IPCP program to monitor and evaluate antibiotic use for their 115 residents. The Infection Preventionist admitted to not having implemented the program and could not provide documentation for ongoing review. The Corporate Nurse confirmed awareness of the issue and stated the goal was to improve the program towards compliance.
The facility failed to notify the Ombudsman of two unplanned, facility-initiated hospital discharges for a resident with multiple medical conditions. The Social Services Director did not include the resident in the monthly discharge lists for November 2023 and March 2024, resulting in a lack of required notification.
The facility failed to ensure accurate completion of MDS assessments for two residents under PASARR and for one resident under the Antipsychotic Medication section. The inaccuracies were due to the MDS Coordinator completing assessments without always having access to the paper charts, leading to incorrect documentation of PASARR evaluations and antipsychotic medication use.
The facility failed to develop a comprehensive care plan for a resident with chronic wounds and edema, despite having orders for Lasix and Bumex. Staff interviews confirmed that the care plan should have been updated to include these conditions.
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for a resident. The resident's MAR for April 2024 showed multiple instances of missing documentation, indicating that the medications may not have been given. The interim DON confirmed that the lack of documentation meant the facility could not prove the medications were administered.
A resident with chronic pain did not receive prescribed Hydrocodone for over a week due to the facility's failure to reorder the medication. Staff did not adequately assess the resident's pain or offer alternative pain management, and the Interim Director of Nursing was unaware of the issue until it was reported.
The facility failed to maintain a qualified administrator from mid-February to early March 2024. Administrator A, who had not yet obtained a license, assumed the role without being listed as a current Missouri Licensed Administrator. The application for a Temporary Emergency License was incomplete and delayed, resulting in a gap in qualified administrative oversight.
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Failure to Maintain Resident Dignity and Respond to Requests
Penalty
Summary
The facility failed to treat residents with dignity and respect when Resident #64 was allowed to scream, yell obscenities, and make threatening statements in common areas while other residents were present, including Resident #41 in the dining room. Resident #41 had moderate cognitive impairment, dementia, hypertension, and diabetes, and was described as being upset by the repeated yelling and cussing. Resident #64 had severe cognitive impairment, a history of behavioral issues, and a care plan that directed staff to explain inappropriate behavior, intervene to protect the rights of others, and divert the resident with other tasks such as painting, coloring, or journaling. During observation, CNA D walked Resident #64 up and down the hall and into the dining room while the resident yelled statements such as "I hate you," "Go to hell," "I wish I was dead," and "I am going to kill you." Resident #41 remained in the dining room and stated that the yelling and cussing were negative and hard to deal with every day. A visitor also reported that the resident was always shouting and that staff knew about the behavior. The observations showed no staff explaining the behavior to Resident #64, no staff intervening to protect the rights of other residents, and no staff attempting to divert the resident with other activities. The facility also failed to acknowledge Residents #22 and #33 when they rang their call light and asked for a snack. Resident #22 had moderate cognitive impairment, Alzheimer’s disease, diabetes, and anxiety, and Resident #33 had severe cognitive impairment, dementia, anemia, and low sodium in the blood. Both residents had care plans directing staff to meet their physical and emotional needs and encourage use of the call bell for assistance. During observation, the residents repeatedly asked for a snack, CNA D walked past their room several times without acknowledging them, and LPN C later entered, shut off the call light, and brought only the drink cart without snacks. The residents stated they felt disrespected and like a burden when staff did not respond to them.
Failure to Obtain Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care by not obtaining written consent before starting psychotropic medications for four residents. The facility’s Resident Rights policy stated residents have the right to be informed in advance of the risks and benefits of proposed care, treatment alternatives or options, and to choose the option they prefer. Review of records showed Resident #37 was prescribed Buspirone, Escitalopram, and Modafinil, but consent for psychotropic medications was not obtained until 8/28/25, after the medications had already begun in January and February 2025. Resident #5 had Trazodone and Rivastigmine started in August 2025, but consent was not obtained before those starts. Resident #8 had Buspirone and Sertraline started in November 2024, but consent was not obtained until 3/5/25, about four months later. Resident #79 was prescribed Escitalopram, Buspirone, and Modafinil, but consent was not obtained until 8/28/25, after the medications had already begun in January and February 2025. The records identified these medications as antidepressant, anti-anxiety, or other psychotropic-related treatments used for depression, anxiety, behaviors, Alzheimer’s disease, or narcolepsy. During interviews, the DON, an LPN, the corporate nurse, and the Administrator stated that nursing staff, social services, or administration should obtain consent from the resident or family before starting psychotropic medications, and the DON said she was unaware consent was not being done prior to administration.
Failure to Use Required PPE During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when staff did not use appropriate PPE for two residents. The facility’s policies stated that standard precautions include hand washing and wearing gloves, gowns, and masks, and that Enhanced Barrier Precautions (EBP) require gown and glove use during high-contact resident care activities for residents with infections, wounds, or indwelling medical devices. Resident #112 had dementia, diabetes mellitus, fragile skin, and orders for blood sugar checks four times daily and insulin Aspart before meals. During observation, an LPN sanitized hands and administered insulin subcutaneously without wearing gloves. Resident #13 had severe cognitive impairment, cerebral palsy, aphasia, quadriplegia, and was dependent on staff for multiple activities of daily living; the resident also received nutrition by feeding tube and required EBP. During observation, an LPN entered the room to perform tube feeding, used gloves while wiping the bedside table and handling feeding supplies, but did not apply a gown during the tube feeding process despite the EBP sign and supplies being present at the door.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide adequate accommodations for a non-English speaking resident, identified as Resident #104, who primarily spoke Spanish. Despite the resident's care plan indicating the use of a communication board and Google Translate for communication, observations revealed that these tools were not consistently utilized. The resident was often left without engagement or entertainment in their primary language, and staff frequently communicated with the resident in English, which the resident did not understand. Interviews with staff indicated a lack of awareness and training on using communication aids, and the resident's family had to frequently assist with communication and care. Additionally, the facility did not provide appropriate seating accommodations for another resident, identified as Resident #26, during meal times. This resident, who had significant cognitive loss and was dependent on a wheelchair, was observed sitting at a dining table that was too high, causing difficulty in self-feeding. The resident's wheelchair was not appropriately fitted, leading to challenges in reaching the table and resulting in the resident eating with their fingers. Despite recommendations from the therapy department for alternative seating arrangements, such as using an over-bed table, these were not implemented. The facility's failure to accommodate these residents' needs and preferences highlights a lack of adherence to the residents' rights to dignified existence and communication. The absence of a policy on accommodating residents' needs further exacerbated the issue, as staff were not adequately trained or informed on how to effectively communicate and provide care for residents with language barriers or specific physical needs.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This deficiency affected two residents, as evidenced by the review of their medical records. Resident #1's record indicated that the NOMNC was issued and signed on the same day that Medicare Part A benefits were ending, failing to meet the required two-day notice period. Similarly, Resident #93's record showed the NOMNC was also issued and signed on the last day of coverage, not adhering to the mandated timeline. Interviews conducted with the Business Office Manager and the Administrator revealed a lack of awareness and understanding regarding the proper procedure for issuing the NOMNC. The Business Office Manager was unaware that the residents did not receive the notice within the required timeframe, while the Administrator could not recall the specific time frame for issuing the NOMNC and was unsure who was responsible for providing the form to residents. This lack of knowledge and procedural oversight contributed to the facility's failure to comply with the CMS guidelines for notifying residents about the end of their Medicare coverage.
Facility Fails to Maintain Acceptable Noise Levels and Clean Environment
Penalty
Summary
The facility failed to maintain acceptable noise levels and a clean, comfortable environment for its residents, as observed in the cases of two residents. Resident #35, who has significant cognitive loss and uses a wheelchair, was observed in distress due to a continuously beeping door alarm in the Special Care Unit dining room. The alarm was caused by a propped-open patio door, and the resident was seen covering their ear and displaying a distressed expression. Additionally, Resident #77, who has intact cognitive skills but suffers from anxiety and depression, reported being disturbed by a loud clunking noise from a broken smoking cart wheel, which had been an issue for over a month and affected their sleep. The facility also failed to maintain a sanitary and orderly environment, as evidenced by multiple observations of unclean and damaged areas throughout the facility. These included stained carpets, dusty light fixtures, chipped paint, and mold-like substances in air conditioning units. The facility's housekeeping and maintenance policies were not effectively implemented, as indicated by the presence of debris, unpainted drywall patches, and broken equipment. Interviews with staff revealed a lack of communication and follow-up on maintenance issues, contributing to the ongoing deficiencies. Furthermore, the facility did not have a policy on sound levels, which may have contributed to the noise-related issues experienced by the residents. The maintenance director acknowledged awareness of some of the problems, such as the broken smoking cart wheel, but corrective actions were delayed. The Director of Nursing expressed expectations for a clean and comfortable environment, yet the facility's practices did not align with these expectations, resulting in a failure to uphold residents' rights to a safe and homelike environment.
Improper Use of Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the improper use of a seat belt for one resident and locked wheelchair brakes for another. Resident #11, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a seat belt fastened across their lap, which they could not release independently. The facility did not have a physician's order, assessment, or care plan for the use of the seat belt, and staff were unaware of the resident's ability to release it. Interviews with staff and administration confirmed that the seat belt should not have been in use without proper evaluation and documentation. Resident #84, who has significant cognitive loss and uses a wheelchair for mobility, was observed with locked wheelchair brakes, preventing them from moving freely. The resident expressed distress and discomfort, indicating they did not want the brakes locked. Staff interviews revealed that the brakes were locked to keep the resident in place, despite the understanding that locked brakes constitute a restraint if the resident cannot unlock them independently. The resident's care plan did not address the use of locked wheelchair brakes, and staff acknowledged that the brakes should not have been locked without the resident's ability to release them. The facility's failure to obtain necessary physician orders, conduct assessments, and update care plans for the use of restraints resulted in the improper use of a seat belt and locked wheelchair brakes for these residents. The facility's policies and the Missouri Resident Rights emphasize the right of residents to be free from restraints, yet these incidents demonstrate a lack of adherence to these guidelines, leading to the inappropriate restriction of residents' freedom of movement.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its Abuse Prevention Policy by not conducting timely background checks through the Family Care Safety Registry (FCSR) for three employees before they had contact with residents. The policy, dated October 2022, mandates pre-screening of potential employees for a history of abusive behavior. However, the personnel files of a Dietary Aide, an LPN, and a CNA revealed that their FCSR checks were conducted after their hire dates, allowing them to interact with residents without the necessary background screening. Interviews with the Human Resources Manager and the Administrator confirmed that the FCSR checks should have been completed before any employee had contact with residents, highlighting a lapse in the facility's hiring process.
Inaccurate and Untimely MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately and timely for four residents. Resident #72 was discharged to another long-term care facility, but no discharge MDS was completed or submitted. Resident #84 had an admission MDS completed, but no subsequent MDS assessments were completed or submitted for several months. Resident #33 had an admission and a Prospective Payment System (PPS) MDS completed, but no MDS assessments were completed or submitted in the months leading up to their death, and no discharge assessment was completed post-mortem. Resident #39's quarterly MDS failed to reflect their dialysis treatment, despite physician orders and care plans indicating the necessity of dialysis. Interviews with facility staff revealed systemic issues contributing to these deficiencies. The MDS Coordinator acknowledged difficulties in obtaining Registered Nurse signatures, leading to delayed MDS submissions. The Coordinator was unaware of any unsubmitted discharge MDS assessments and could not explain the lack of a current MDS for Resident #84. The Director of Nursing and the Administrator both expressed expectations for timely and accurate MDS submissions, yet these expectations were not met, resulting in incomplete and inaccurate resident assessments.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing critical care areas. For Resident #39, the care plan did not include the use of a bilevel positive airway pressure (BIPAP) machine, despite the resident's respiratory conditions and the resident's expressed desire for its use at night. Additionally, the care plan did not address the use of side rails, which the resident used for repositioning in bed. Observations and interviews revealed that the BIPAP machine was not consistently applied, and the side rails were not documented in the care plan, despite being used by the resident. Resident #113's care plan also lacked documentation regarding the use of side rails, which were present on the resident's bed. The resident had involuntary movements and used the side rails to assist with repositioning, yet this was not reflected in the care plan. Staff interviews indicated a lack of awareness about the reason for the side rails, and the side rail evaluation did not support their use, highlighting a disconnect between the resident's needs and the care plan. For Residents #26 and #84, the facility failed to address significant weight loss in their care plans. Both residents experienced substantial weight loss over several months, yet their care plans did not include interventions to address or mitigate this issue. The MDS coordinator and the Director of Nursing acknowledged the expectation for care plans to include such interventions, but the care plans remained incomplete, indicating a failure to update and implement necessary care strategies for these residents.
Failure to Provide Timely Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services for dependent residents who were unable to perform activities of daily living, specifically in providing perineal care at least every two hours. This deficiency affected two residents, both of whom were always incontinent of bowel and bladder and dependent on staff for all ADLs. Observations showed that staff did not reposition or assess the need for incontinent care for these residents over several hours, despite the facility's policy requiring routine perineal care after each incontinent episode. Resident #11, with severe cognitive impairment and diagnoses including cerebral palsy and quadriplegia, was observed lying in bed without being repositioned or provided incontinent care for over three hours. Interviews with CNAs revealed that they had not provided the necessary care since arriving at work, acknowledging that the resident should be repositioned and provided care every two hours. The resident's care plan did not address incontinence or incontinent care, contributing to the oversight. Similarly, Resident #19, with moderate cognitive impairment and diagnoses including Guillain-Barre syndrome, was observed in a room with a strong smell of urine, indicating a lack of timely incontinent care. Staff interviews confirmed that the resident had not been repositioned or provided perineal care since the start of their shift. The care plan for this resident also failed to address routine incontinent care, leading to the deficiency in maintaining the resident's personal hygiene.
Inadequate Hydration and Weight Loss Management
Penalty
Summary
The facility failed to adequately address significant weight loss and provide sufficient hydration for several residents. Resident #26 experienced a 13.56% weight loss over six months, with no care plan or interventions documented to address this issue. Observations revealed that the resident was not consistently provided with fluids or assistance during meals, contributing to inadequate hydration and nutrition. Despite a physician's order for an appetite stimulant, there was no evidence of consistent follow-up or notification of the physician regarding the resident's weight loss. Resident #84 also suffered from significant weight loss, losing 15.34% of their body weight over three months. The resident's care plan did not include specific interventions to address this weight loss, and observations showed a lack of fluids and snacks available to the resident. Staff did not consistently assist the resident during meals, and there was no documentation of efforts to encourage or monitor the resident's food and fluid intake. Additional residents, including #35, #57, and #4, were observed to have inadequate hydration, with inconsistent documentation of fluid intake and a lack of fluids available at bedside. Staff interviews revealed a lack of consistent procedures for providing fluids and snacks, with discrepancies in the reported times and frequency of hydration cart rounds. The facility's failure to adhere to its hydration policy and lack of individualized care plans for weight loss and hydration contributed to these deficiencies.
Failure to Assess Bed Rail Entrapment Risks
Penalty
Summary
The facility staff failed to properly assess residents for the risk of entrapment from bed rails before their installation. This deficiency was observed in four out of 21 sampled residents. The facility did not have a policy on entrapment, and there were no physician's orders for the use of side rails for these residents. The residents involved had various medical conditions, including cognitive impairments, mobility issues, and other health diagnoses, which necessitated careful consideration before the use of bed rails. For Resident #39, the facility did not complete a full entrapment assessment, and the bed's dimensions were not appropriately measured against FDA recommendations. Despite the resident's request for side rails to assist with repositioning, there was no documented physician's order for their use. Similarly, Resident #113 had side rails installed without a proper assessment or physician's order, and the entrapment evaluation was incomplete. The resident's involuntary movements were noted, but the side rail committee had recommended against their use. Resident #54 also had side rails installed without a physician's order, and the entrapment evaluation was not fully documented. The resident used the side rails for mobility assistance, but this was not care planned. Lastly, Resident #104 had side rails without a completed side rail evaluation form or physician's order. The entrapment evaluation was incomplete, and staff were unsure of the necessity of the side rails. The facility's maintenance director was tasked with completing entrapment evaluations, but there was a lack of clarity and consistency in the process.
Medication Administration Errors and Delays in Insulin Management
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20% error rate. This was observed through various incidents involving five residents. For instance, Resident #4, who has diabetes mellitus and chronic obstructive pulmonary disease, had their blood sugar checked without allowing the alcohol wipe to air dry, contrary to proper procedure. Similarly, Resident #15's blood sugar was checked after only a four-second air dry, and Resident #43's blood sugar was checked after a six-second air dry, both of which were insufficient according to the facility's standards. Resident #91 experienced issues with the application and removal of Salonpas patches. The patches were not removed at the scheduled time, and the MAR inaccurately indicated that they had been removed. This oversight was confirmed when the nurse found the patches still on the resident the following morning, despite documentation stating otherwise. The resident reported shoulder pain and expressed that the patches were supposed to be removed at night. Resident #103, who requires insulin for diabetes management, did not receive their meal within the recommended time frame after insulin administration. The resident's blood sugar was checked, and insulin was administered according to the sliding scale, but the meal was delayed by approximately an hour. This delay was contrary to the manufacturer's guidelines for Humalog insulin, which should be administered no earlier than 10 minutes before a meal. The LPN involved assumed the resident had gone to the dining room, leading to the oversight.
Failure to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to provide food that was palatable and attractive, affecting two residents. Resident #85, who had severe cognitive impairment and required assistance with eating, was observed struggling with dry rice that was served in the form of an ice cream scoop. The resident expressed that the food was very dry. The care plan for Resident #85 indicated the need to obtain and update food preferences and serve the diet as ordered, but there was no policy provided for resident food preferences. Resident #52, with moderate cognitive impairment and a history of stroke and dementia, was observed having difficulty eating dry chicken and was served rice despite disliking it. The meal ticket indicated a preference against rice, yet it was still served. The Dietary Manager was unaware of any current food complaints, and the Administrator expected food to be served palatably. The facility census was 103, and the deficient practice was noted during observations and interviews.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain the physical environment in good repair, as observed in various areas including the Special Care Unit, dining/activity room, nurse's station, and entrance areas. Specific issues included dead bugs, dust, and debris in light fixtures, scratched and chipped paint on doors, scuffed and stained floor tiles, and black mold-like substance on PTAC units. Additionally, there were cobwebs, rusted and chipped window frames, and cracked tiles in several locations. These deficiencies were noted to potentially affect all residents, with a census of 103. Interviews with housekeeping and maintenance staff revealed a lack of clarity and coordination in responsibilities for cleaning and repairs. Housekeeping staff indicated that maintenance was responsible for high dusting and cleaning lights, while the maintenance director stated that housekeeping should handle these tasks. The maintenance director also acknowledged awareness of rusted door frames and the need for patching and painting but noted that no contractor had been contacted for repairs. Furthermore, there was no written plan for the repair and upkeep of the building, and the administrator expressed an expectation for the building to be clean and in good repair.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, flies, and wasps in various areas, including resident rooms, dining rooms, and hallways. Observations on multiple occasions revealed gnats in a specific room, flies in the dining room, and both flies and gnats in another room, where a fly strip with dead flies was also noted. A resident reported frequent fly infestations in their room, with flies landing on them and crawling on their bed. Additionally, wasps were observed on the wall of the Special Care Unit's nursery room, and another room had multiple flies crawling on a resident and their bed. The facility did not provide a pest control policy, and the review of pest service invoices indicated that the pest control program was limited to outside fly control services conducted monthly from July to September. During an interview, the Administrator acknowledged the existence of a pest control program but noted that fly strips should not be present in resident rooms and stated that pest control would be notified of the concerns.
Resident Dignity and Respect Deficiency
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the actions of staff towards a resident with significant cognitive impairment. The resident, who had a diagnosis of dementia and anxiety, was observed sitting in the hallway when a Certified Nurse Aide (CNA) grabbed and shook the resident's shirt despite the resident's repeated requests to stop. The CNA continued this behavior, dismissing the resident's protests as playful interaction. This incident was witnessed by surveyors and highlighted a lack of respect for the resident's right to a dignified existence. Additionally, the resident was subjected to disrespectful treatment by a Licensed Practical Nurse (LPN) who yelled at the resident for self-propelling their wheelchair in the hallway. The LPN repeatedly called the resident back to the nurses' station, restricting their movement within the secured care unit. The resident expressed dissatisfaction with being confined to certain areas, indicating a disregard for their right to self-determination. Interviews with the Director of Nursing and the Administrator confirmed that such actions were inappropriate and not aligned with the facility's expectations for resident care.
Failure to Assist Resident in Obtaining Hearing Aid
Penalty
Summary
The facility failed to assist a resident, identified as Resident #82, in obtaining a hearing aid, despite the resident's diagnosis of bilateral sensorineural hearing loss. The resident's care plan did not address the hearing issues or the need for a hearing aid, and there was a lack of documentation regarding the process of obtaining the hearing aid. The resident had undergone a hearing test at a local hospital but had not received the hearing aid, and there was no communication with Social Services about the issue. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining the hearing aid. The Social Services Director indicated that the transportation person was responsible for scheduling appointments and following up, but did not document any information in the resident's chart. The transportation person confirmed they were waiting for Medicaid approval and did not have access to charting, while the Director of Nursing stated that Social Services should document the process. The Administrator expected the Social Services Director to play a larger role in obtaining the hearing aid, rather than leaving it to transportation.
Significant Medication Error Due to Delayed Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving a resident who did not receive a meal within the required time after receiving fast-acting insulin. The facility's policy for medication administration requires that medications be administered as prescribed and in accordance with professional standards. However, the policy did not specify the time frame for providing a meal after administering insulin. The manufacturer's guidelines for Humalog insulin indicate that it should be administered 15 minutes before a meal. In this case, the resident's blood sugar was checked, and 4 units of Humalog insulin were administered at 11:54 A.M. The resident did not receive a meal until 12:52 P.M., nearly an hour after the insulin was given, contrary to the manufacturer's guidelines. Observations showed that the resident remained in their room without being checked on by staff after receiving insulin. The LPN responsible for administering the insulin assumed the resident had gone to the dining room to eat. However, the resident stayed in their room and expressed hunger at 12:42 P.M. The Director of Nursing confirmed that the physician's orders should be followed and that Humalog should be given no earlier than 10 minutes before a meal. The delay in providing the meal after insulin administration was identified as a significant medication error, as the resident should not have waited 45 minutes to an hour to eat after receiving fast-acting insulin.
Failure to Complete CNA Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of nurse aides at least once every 12 months and did not provide regular in-service education based on the outcome of the review. This deficiency was identified through interviews, record reviews, and a review of the facility's policy. The facility's policy, dated 07/01/03, mandates that all new employees, including CNAs, must undergo orientation within the first 40 hours of employment and complete specific training topics annually. However, a review of 52 CNA personnel files revealed that the facility did not adhere to this policy, as no performance reviews or competency evaluations were completed for the CNAs within the required 12-month period. During an interview, the Executive Director admitted that she did not have the CNAs' competency evaluations and could not provide the necessary documentation. This lack of adherence to the facility's policy and federal regulations resulted in the facility failing to ensure that CNAs received the required performance reviews and in-service education, which are critical for maintaining the quality of care provided to residents.
Failure to Ensure Proper Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation, it was noted that the freezer contained an open bag of hamburgers, eight plastic containers ready for use were dirty with dried food particles, and two metal shelving units with dust collected on them. Additionally, during a tray line observation, a dietary cook handled food and equipment without performing hand hygiene. The cook unplugged a hot box with bare hands, transported it through hallways, and continued to serve food after picking up utensils and a pen from the floor without washing hands. Interviews with the dietary cook and the dietary manager revealed a lack of awareness and adherence to proper hand hygiene and sanitization practices. The dietary manager acknowledged the need to stay within regulations and maintain a clean kitchen, while the administrator emphasized the importance of sanitizing and washing hands when processing and handling food. These observations and interviews indicate a failure to follow the facility's policy on sanitizing equipment and food contact surfaces, posing a risk to the health and safety of the residents.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to ensure a written transfer agreement with a hospital was in effect to assure residents of timely hospital admission when medically appropriate and necessary information would be exchanged between providers. On 04/18/24, the written transfer agreement(s) with the community hospital(s) was requested from the Executive Director, but no written transfer agreement was provided. During an interview on 04/19/24, the Executive Director stated that the facility did not have a written transfer agreement, believing it was not a requirement in Missouri and that the community understood residents would be treated at the hospital without one. The Executive Director was unaware of the Federal requirement for a written transfer agreement and had never seen one at the facility since she had been working there for a few months. She stated she would immediately begin the process of obtaining a written transfer agreement with the community hospital.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain their established infection prevention and control program (IPCP) for surveillance, tracking, trending, and administration of corrective actions to prevent and control the spread of identified infections. The facility's policy for IPCP included completing a monthly infection control surveillance log with detailed information about each infection case, such as the resident's identifying information, infection onset date, diagnostic test outcomes, infection site, culture results, and resolution date. However, this surveillance action was not implemented, leading to a lack of documentation and tracking of infections within the facility, which had a census of 115 residents. During an interview, the Infection Preventionist (IP) stated she had completed her certification process recently and had been in the position for one month. She was unaware of the previous IP or if the facility had employed one in the past several months. The IP acknowledged the lack of documentation for tracking and trending infections and was trying to improve the process. The Corporate Nurse also confirmed awareness of the documentation deficiencies and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure residents who smoked were assessed and that supervision was provided in accordance with their assessed needs. Residents were observed smoking unsupervised outside of designated areas. The facility did not have a system in place to individually identify and determine if residents needed staff to maintain their smoking materials, care plan such needs, and implement a monitoring system for five of 22 residents who smoked. Additionally, the facility failed to develop a care plan for one of the residents who smoked. One resident, R11, was readmitted with diagnoses including chronic obstructive pulmonary disease and had a BIMS score indicating moderate cognitive impairment. The resident's care plan did not reflect that they were a smoker, and the smoking evaluation tool was incomplete. Another resident, R81, who was cognitively intact, was observed smoking outside the designated area without supervision. The smoking evaluation tool for R81 was also incomplete, and the resident admitted to obtaining cigarettes and a lighter from another person in the facility. Other residents, including R17, R5, and R87, were also observed smoking without proper supervision and outside designated areas. R17, who was cognitively intact, kept smoking materials in their scooter basket and expressed dissatisfaction with the lack of supervision. R5, who had a traumatic brain injury and was cognitively intact, kept cigarettes in a lockbox in their room and smoked outside the building unsupervised. R87, who had chronic obstructive pulmonary disease and moderate cognitive impairment, was observed smoking and admitted to having access to cigarettes despite the facility's policy. The facility's staff admitted to forgetting to document necessary information in the smoking evaluation tools, and the Executive Director confirmed that residents should be supervised while smoking in designated areas.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure prescribed medications were administered at the prescribed time and were available for administration for eight of 13 residents. This resulted in 29 medication errors out of 59 opportunities, leading to a medication error rate of 49.15%. The facility's policy mandates that medications be administered in accordance with written orders of attending physicians and within a specific time frame, which was not adhered to in these cases. For instance, one resident did not receive a prescribed patch because the LPN assumed the resident would refuse it, while another resident received their medication late due to the LPN's delay. Additionally, a resident did not receive their pain medication because it was not available in the facility, and the LPN failed to reorder it in a timely manner. Another resident did not receive their insulin as scheduled because the LPN was unable to administer it on time. Other residents also experienced delays in receiving their medications, including those for diabetes, pain management, and other chronic conditions. The interim director of nursing confirmed that medications should be given at the time ordered by the physician and acknowledged the lapses in timely administration. These failures highlight significant issues in medication management and adherence to physician orders within the facility.
Failure to Implement and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain their infection prevention and control (IPCP) program critical element to monitor and evaluate antibiotic use and to track measures of usage in the facility for their entire population of residents, which had a census of 115. The facility's policy on the Antibiotic Stewardship Program, updated on 10/01/22, outlined guidelines for monitoring antibiotic use, including collecting reports on antibiotic susceptibility patterns, reviewing the appropriateness of antibiotic administration, establishing standards for clinical monitoring of adverse drug events from antibiotic use, and using microbiology culture data to guide future antibiotic selection. During an interview, the Infection Preventionist (IP) acknowledged familiarity with the IPCP standards and goals but admitted to not having implemented them yet and could not provide documentation for the facility's ongoing review of antibiotic stewardship. The Corporate Nurse also confirmed awareness of the lack of documentation and stated that the goal was to improve the program towards compliance with IPCP regulations, policies, and procedures.
Failure to Notify Ombudsman of Unplanned Hospital Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of two unplanned, facility-initiated hospital discharges for a resident. The resident, who had diagnoses including spinal stenosis, osteomyelitis, and a right leg below-the-knee amputation, experienced an unplanned discharge to the hospital on two separate occasions. The first discharge occurred on 11/09/23 due to an urgent medical need related to a wound infection, and the second discharge occurred on 03/27/24 due to a non-healing wound on the left foot with drainage and odor. In both instances, the Ombudsman was not notified of the discharges as required. The Social Services Director (SSD) typically provided a monthly report of all discharges to the Ombudsman but failed to include the resident in question on the discharge lists for November 2023 and March 2024. The SSD acknowledged that the resident did not appear on the discharge list for those months and admitted that an extra step was needed to ensure hospitalizations were included. The failure to notify the Ombudsman was confirmed during staff interviews and a review of the facility's records.
Inaccurate MDS Assessments for PASARR and Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment under the Pre-Admission Screening and Resident Review (PASARR) for two residents and under the Antipsychotic Medication section for one resident. Resident 7 was admitted with diagnoses including schizophrenia and anxiety disorder. Despite having a PASARR Level II evaluation indicating a serious mental illness and requiring a structured environment and medication management, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. Additionally, the MDS assessment inaccurately documented that the resident had not received antipsychotic medications, despite records showing a prescription for olanzapine for schizophrenia. The MDS Coordinator admitted to completing the MDS without always having access to the paper chart, leading to these inaccuracies. Resident 41 was admitted with diagnoses including intellectual disabilities, schizophrenia, and major depressive disorder. The PASARR Level II Evaluation Report indicated a serious mental illness but no intellectual disability requiring specialized mental health services. However, the MDS assessment inaccurately documented that the resident had not been evaluated by PASARR Level II. The MDS Coordinator also admitted to not being aware of the PASARR Level II evaluation for this resident and completing the MDS without always having access to the paper chart, resulting in the inaccurate documentation.
Failure to Develop Comprehensive Care Plan for Chronic Wounds and Edema
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan to address a resident's chronic wounds and edema. The resident, who was admitted with diagnoses including edema and stroke affecting the right side of the body, had orders for Lasix and Bumex to manage edema. Despite these orders and the resident's ongoing treatment for chronic wounds and edema, the care plan did not include any specific measures for these conditions. This oversight was confirmed through a review of the resident's electronic medical record and interviews with staff members. During interviews, the Administrator acknowledged that care plans should be updated based on information gathered in morning meetings. The Minimum Data Set Registered Nurse (MDSRN) also confirmed that the chronic edema and wound care should have been included in the care plan and expressed uncertainty about how this was missed. The resident was not interviewable, and the facility census at the time was 115.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer physician-ordered glaucoma eye drops as prescribed for one resident (R44) out of a sample of 29 residents. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had specific orders for timolol, latanoprost, Trusopt, and Brimonidine eye drops to be administered at various times throughout the day. However, a review of the resident's Medication Administration Record (MAR) for April 2024 revealed multiple instances where the administration of these medications was not documented, indicating that the medications may not have been given as prescribed. During an interview, the interim director of nursing confirmed that the absence of documentation in the MAR boxes under the specified dates meant that the facility could not prove the medications were administered. This failure to document and potentially administer the prescribed medications constitutes a deficiency in meeting professional standards of quality care for the resident.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that pain medication (Hydrocodone) was available for a resident (R24) who required it. R24, who was admitted with diagnoses including polyneuropathy, diabetes mellitus, rheumatoid arthritis, pain, and a history of right femur fracture, had a physician's order for Hydrocodone-Acetaminophen 5-325 mg to be administered twice a day. However, from 04/11/24 to 04/19/24, the medication was not available, and the resident did not receive the prescribed pain management. During this period, the resident reported moderate pain levels and expressed frustration over the lack of effective pain relief, despite repeatedly asking staff about the medication's availability. The staff failed to assess the resident's pain adequately or offer alternative pain management solutions during this time. Additionally, the resident's Medication Administration Record (MAR) indicated that the pain medication was not administered as ordered, and the pain scale was documented as zero for each shift, which contradicted the resident's reported pain levels. Interviews with staff revealed a lack of knowledge and training on reordering medications, and the Interim Director of Nursing (IDON) was unaware of the issue until it was brought to their attention. The IDON stated that emergency pharmacies could have been used to obtain the medication promptly, but this option was not utilized. The facility's failure to ensure the availability of prescribed pain medication and to provide appropriate pain management for R24 resulted in the resident experiencing unmanaged pain for an extended period.
Failure to Maintain Qualified Administrator
Penalty
Summary
The facility failed to maintain a qualified administrator on duty from February 15, 2024, to March 3, 2024, as required by state laws. Administrator B informed the state survey agency on February 14, 2024, that they were no longer the Administrator of record. Subsequently, Administrator A, who had completed the Administrator in Training program but had not yet taken the test to obtain an administrator license, assumed the role. However, Administrator A was not listed as a current Missouri Licensed Administrator, and there was uncertainty about whether anyone at the corporate level was a licensed administrator in Missouri to act in the interim. The application process for Administrator A's Temporary Emergency License (TEL) was mishandled. A partial application was submitted on February 15, 2024, but it lacked the full licensure application, application fee, and required records such as a birth certificate and proof of high school graduation. Despite follow-up emails from the Missouri Board of Nursing Home Administrators (MBNHA) on February 20 and February 26, 2024, the necessary documents were not promptly provided. The full application and fee were only received on February 27, 2024, but still lacked some required documents. Consequently, a TEL was not issued to Administrator A until March 4, 2024.
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Illustrative
What surveyors actually found near you
We read the 844 citations issued within 25 miles in the last 12 months — including the 20 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccrite Plaza At Briarcliff Skilled Facility | 1.4 mi | ★★★★★ | 4 | 0 |
| Northland Rehabilitation & Health Care Center | 4.9 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort Kansas City, Llc | 5.1 mi | ★★★★★ | 11 | 0 |
| Linden Woods Village | 5.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Kansas City | 5.8 mi | ★★★★★ | 20 | 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.