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 West Vue Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of falls, and total dependence for transfers was lowered to the floor during a transfer with a mechanical ceiling lift when the device reportedly malfunctioned and CNAs manually assisted the resident to the floor and then to a Geri chair. The CNAs did not immediately notify the nurse, and the initial nursing assessment performed during a throat swab was not documented in the record. Bruising and discomfort of the right lower extremity were noted later in the morning, and the physician and family were not documented as being notified until late in the day, with no same-day progress notes describing a head-to-toe post-fall assessment, the incident details, or timely family notification, despite facility leadership stating that immediate assessment and notification are expected after a fall.
A resident with severe cognitive impairment, total dependence for ADLs, and a history of falls was being transferred with a mechanical ceiling lift when the device malfunctioned and the resident was lowered to the floor by a CNA. The CNAs did not immediately notify the nurse and moved the resident from the floor to a Geri chair using a gait belt and a fireman lift before any nursing assessment occurred, despite facility expectations that a nurse must assess a resident in place after any fall. Although an RN later entered the room and reportedly performed a head-to-toe assessment, there was no corresponding post-fall assessment or skin assessment documented in the record for that day, and no detailed incident note, even as bruising and discomfort of the right lower extremity were later observed and reported. This sequence of actions and omissions failed to meet the facility’s own falls protocol and professional standards requiring immediate nursing assessment and thorough documentation after a fall.
The facility failed to provide and document training and competency assessment on mechanical ceiling lift use for a CNA who had been employed for several months. The existing orientation policy did not address training on facility equipment, including mechanical lifts, and review of the CNA’s training record showed no education or competency checks related to safe lift use. The Administrator, DON, Director of Staff Development, and Nursing Manager each stated they expected CNAs to be trained and competent in mechanical lift use, yet confirmed that this CNA had not received such training, while the CNA reported having no training or demonstrated competency on the mechanical ceiling lift used to transfer a resident.
The facility failed to maintain sanitary conditions in its food service areas, with issues such as undated food items, improper storage, and significant cleanliness problems. Observations revealed grime, debris, and ice build-up in various kitchen areas, while interviews confirmed that these areas should have been cleaned according to policy. Maintenance and supply delays contributed to unresolved issues, posing a risk of cross-contamination and food-borne illness for residents.
A resident with hypertension did not receive timely segmental pressures and arterial duplex tests as ordered by the physician. The facility failed to document the completion of these tests, and the resident experienced ongoing leg and foot pain. The DON was unaware of the new imaging order, and the resident reported that Tylenol was not always effective in managing the pain.
The facility failed to ensure an appropriate diagnosis for an antipsychotic medication for a resident and did not limit PRN orders for psychotropic medications to 14 days for two other residents. A resident was prescribed Abilify without a specific diagnosis, and two residents had PRN orders for hydroxyzine and lorazepam without stop dates. Staff interviews revealed a lack of awareness regarding the necessity of proper diagnoses and adherence to PRN limits.
The facility failed to maintain a homelike environment, as personal items were found on light fixtures in several resident rooms. Despite the facility not recommending this practice, it occurred, and there was no policy in place to address it. Interviews with the Maintenance Supervisor, DON, and Administrator confirmed the lack of adherence to recommended practices.
Failure to Timely Notify Family and Physician and Complete Post-Fall Assessment After Lift Incident
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a resident’s family/representative and physician of a significant change in condition following a fall from a mechanical ceiling lift, as well as incomplete post-fall assessment and documentation. The facility’s Falls – Clinical Protocol required that families be notified of all falls but did not specify a timeframe for notification or address post-fall assessments, monitoring, or documentation. For the involved resident, who had severe cognitive impairment, a history of falls, arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and dependence on staff for all transfers and ADLs, there was no documentation of a post-fall assessment, post-fall skin assessment, or timely communication to the physician or representative on the date of the incident until late in the afternoon. On the day of the incident, the resident, who was care planned as a Hoyer lift transfer and at risk for falls, was being transferred from bed to a Geri chair with a portable ceiling lift by a CNA. The CNA reported that the lift broke and the resident began to come down, so the CNA grabbed the resident, slid the resident against the CNA’s body, and lowered the resident to a seated position on the floor. Another CNA responded to yelling, found the resident seated on the floor in front of the first CNA, and together they used a gait belt and a fireman lift to move the resident to a Geri chair. Both CNAs reported no immediate distress and did not immediately notify the nurse, with one CNA stating the nurse was busy and they did not feel the resident was injured, and the other CNA acknowledging awareness that immediate notification should have occurred. RN C later entered the room to perform a throat swab and assessed the resident, reportedly noting no injuries or immediate distress at that time, but did not document this assessment in the progress notes. Mid-morning, staff observed bruising and discomfort in the resident’s right lower extremity, and the physician was contacted for a STAT x-ray order. Documentation shows that family notification of the fall and physician contact were not recorded until late afternoon, and there were no progress notes on the date of the incident addressing a head-to-toe assessment, family contact, or a detailed description of the incident. The resident’s responsible party reported not being informed of the fall until early afternoon, despite a spouse being present in the facility earlier that morning and not being told of the incident. Facility leadership, including the DON, Nursing Manager, and Administrator, stated their expectation that nurses immediately assess residents and contact the physician and family after a fall, which did not occur in this case.
Failure to Immediately Assess and Document Resident After Witnessed Fall During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed professional standards of practice by not immediately assessing a resident after a witnessed fall and not documenting a timely post-fall assessment. The facility’s Falls – Clinical Protocol required that residents who fall be assessed for injury at the time of the fall, with nursing assessment and documentation of vital signs, injury, musculoskeletal function, cognition, neurological status, pain, and details of the fall. The protocol also required assessment and charting for 72 hours and notification of family for all falls. Despite these requirements, there was no documentation of a post-fall assessment or post-fall skin assessment for the resident on the date of the incident. The resident involved had an admission date of 11/16/22 and diagnoses including arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and a history of falling. The resident’s MDS showed severely impaired cognition and dependence on staff for all ADLs and transfers, and the care plan identified the resident as at risk for falls due to weakness, impaired vision, dementia, medications, inability to stand, agitation, restlessness, and poor safety awareness. The care plan also specified use of a Hoyer lift for transfers. On the day of the incident, staff used a portable ceiling lift to transfer the resident after a shower. CNA A reported that the lift broke and the resident began to drop, so CNA A grabbed the resident, pulled the resident toward his/her chest, and slid the resident to a seated position on the floor, resting on the CNA’s feet. CNA B entered the room and observed the resident seated on the floor in front of CNA A. CNA A and CNA B did not immediately notify the nurse of the fall because they did not feel the resident was injured and believed the nurse was busy. Instead, they assisted the resident from the floor to a Geri chair using a gait belt and a fireman lift without a prior nursing assessment. This action was contrary to the expectations described by multiple staff and leadership interviews, which stated that when a resident falls or is found on the floor, the nurse should be called immediately, the resident should not be moved until assessed by the nurse, and only the nurse should perform the post-fall assessment. Although the incident report and progress notes indicate that RN C later entered the room and performed a head-to-toe assessment with no injuries noted, there was no corresponding progress note documenting this assessment or a detailed description of the incident on that date, and there was no documented post-fall skin assessment. Later that day, staff reported bruising and discomfort in the resident’s right lower extremity, leading to physician notification and orders for x-rays, but the initial failure to immediately notify the nurse, perform, and document a timely post-fall assessment constituted the cited deficiency.
Failure to Train CNA on Mechanical Ceiling Lift Use
Penalty
Summary
The facility failed to implement and maintain an effective training program for mechanical ceiling lift equipment for at least one CNA, resulting in a deficiency related to staff training and competency. The facility’s written policy titled “Orientation Program for Newly Hired Employees, Transfers, Volunteers,” revised May 2019, did not address training on facility equipment, including mechanical lifts. Review of CNA A’s training record, with a hire date of 10/08/25, showed no documentation of education or competency validation on the safe use of mechanical lifts. The Administrator stated she would expect CNAs to be trained and competent to use mechanical lifts prior to transferring a resident, and the Director of Staff Development confirmed that CNA A had not received training or a competency check for a mechanical lift. The DON stated she would expect CNAs to be trained on the mechanical ceiling lift if they cared for a resident who utilized it, but acknowledged CNA A did not have such training, and the Nursing Manager confirmed no one had trained CNA A on the mechanical ceiling lifts. In a phone interview, CNA A reported working at the facility for three months without any training or demonstrated competency on the mechanical ceiling lift used to transfer a resident. This deficiency was identified through interviews and record review, which showed the absence of a facility policy on employee training and competencies specific to equipment, and the lack of documented training and competency assessment for CNA A regarding mechanical ceiling lifts, despite expectations from leadership that such training should occur.
Sanitation Deficiencies in Food Service Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during multiple inspections. Key issues included undated and unlabeled food items, such as a partially full storage bin of powdered milk, and improper storage practices, with food containers placed directly on the floor. The kitchen areas were found to have significant cleanliness issues, including oily film and grime on various surfaces, white build-up on ice machines and dishwashers, and pooled water in the dishwashing area. Additionally, the walk-in refrigerator and freezer had scattered food debris and ice build-up, with several food items covered in thick ice. Further observations revealed that the dry food storage area had undated cans with a brown substance, scattered food debris, and improperly stored food items on the floor. The Whispering Pines kitchen had a ceiling diffuser with dust and a brown substance, while the Flowering Dogwood kitchen had white and brown substances on the ice machine and refrigerator dispenser. The Sleepy Oaks kitchen had food debris on the floor, a red substance and black debris in the refrigerator, and grime in the oven. Interviews with dietary aides and the dietary manager confirmed that these areas should have been cleaned and maintained according to the facility's sanitation policy. Interviews with the dietary manager and maintenance director indicated that there were delays in receiving cleaning supplies and that maintenance issues, such as ice build-up in the freezer, had been reported but not resolved. The administrator acknowledged the need for adjustments to prevent water splashing in the dishwashing area and confirmed that food should not be stored on the floor. The maintenance director was aware of the ice build-up in the freezer and stated that some had been removed, but it should not have been present. Overall, the facility's failure to adhere to its sanitation policy and maintain clean and sanitary conditions in food service areas posed a risk of cross-contamination and food-borne illness for all residents.
Failure to Follow Physician Orders for Diagnostic Tests
Penalty
Summary
The facility failed to adhere to physician's orders for a resident diagnosed with hypertension, specifically by not obtaining segmental pressures and an arterial duplex in a timely manner. The physician's order sheet dated 11/14/24 included an order for segmental pressures of the bilateral lower extremities, and the provider progress notes included an order for an arterial duplex. However, there was no documentation that the segmental pressures were completed or that a findings report was generated. The arterial duplex was eventually completed on 01/23/23, revealing mild to moderate peripheral vascular disease and moderate stenosis in the left lower extremity. Interviews and observations revealed that the resident experienced pain in the legs and feet, with complaints of pain when touched and discomfort when wearing shoes. The Director of Nursing acknowledged that the order for segmental pressures was not followed up on due to it not being entered into the system, and there was a lack of awareness regarding the new imaging order. The resident reported that Tylenol provided by the nurse did not always alleviate the pain, and the resident was observed with non-slip socks and legs resting on a pillow.
Failure to Ensure Proper Diagnosis and PRN Limits for Psychotropic Medications
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for one resident and did not limit the use of PRN orders for psychotropic medications to 14 days for two other residents. Resident #16 was prescribed Abilify for unspecified dementia with behavioral disturbances, but the facility did not provide a specific diagnosis or identify the behaviors addressed by the medication. Observations showed the resident exhibited nonsensical speech and occasional yelling, but these behaviors were not clearly linked to the medication's purpose. Interviews with staff revealed a lack of awareness regarding the necessity of a proper diagnosis for antipsychotic prescriptions. Additionally, the facility did not adhere to the 14-day limit for PRN psychotropic medications for Residents #71 and #267. Resident #71 had a PRN order for hydroxyzine without a stop date, and Resident #267 had a PRN order for lorazepam also lacking a stop date. Interviews with the RN, DON, and Administrator indicated a lack of awareness and adherence to the requirement for PRN psychotropic medications to have a 14-day stop date or a physician reevaluation for an extended period. The facility did not provide a policy for appropriate diagnosis and PRN psychotropic medication use.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple observations of personal items placed on light fixtures in resident rooms. These items included figurines, picture frames, stuffed animals, and decorative objects, which were found on light fixtures in several rooms. The presence of these items on light fixtures was not recommended by the facility, as confirmed by interviews with the Maintenance Supervisor, the Director of Nursing (DON), and the Administrator. The Maintenance Supervisor acknowledged that some residents had items on their lights, although it was not recommended. The DON also confirmed that while it was not recommended, it happened, and residents usually had to purchase shelves themselves for their belongings. The Administrator stated that items should not be on top of light fixtures and expected staff to inform maintenance to install shelves for residents' belongings. The facility did not provide a policy for maintaining a homelike environment, which contributed to the deficiency.
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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 West Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, West Plains | 0 mi | ★★★★★ | 0 | 0 |
| Brooke Haven Healthcare | 0.9 mi | ★★★★★ | 9 | 0 |
| Willow Care Nursing Home | 18.7 mi | ★★★★★ | 8 | 0 |
| Mountain View Healthcare | 21.6 mi | ★★★★★ | 0 | 0 |
| Shady Oaks Healthcare Center | 23.3 mi | ★★★★★ | 4 | 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.