Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Westwood Hills Health & Rehabilitation Center during CMS and state inspections, most recent first.
Care plans were not updated with individualized fall interventions for two residents who had repeated falls. One resident with Alzheimer's disease, dementia, COPD, and major depressive disorder had multiple unwitnessed and witnessed falls with injuries including skin tears and a forehead raised area, but the care plan did not address falls. Another resident with type II DM, COPD, and major depressive disorder had several unwitnessed falls with injuries including an abrasion and a raised area above the eye, yet the care plan only referenced one earlier wheelchair slide and did not reflect the later falls; staff interviews confirmed care plans should be revised after falls.
Failure to provide appropriate pain management for a nonverbal resident with chronic pain, severe dementia, and sacral/coccyx wounds. The resident repeatedly moaned, grimaced, and resisted during incontinent and wound care, including waiting while on his/her side for wound care to begin. Staff said they believed the resident was in pain, but the DON said she had not been aware of the pain and staff were not aware the PRN hydrocodone/APAP could be given before care.
Unlabeled and expired medications were found in two medication carts for two residents. Surveyors observed opened bottles of medications and biologicals without required labels or open dates, along with multiple expired medication cards and an opened protein supplement that was not dated. Facility policy required medications to be clearly labeled and opened multi-dose items to be dated and discarded within 28 days unless otherwise specified.
Infection Control Failure During Wound Care: An RN failed to follow the facility’s wound care protocol during treatment of a resident with stroke, vascular dementia, dysphagia, and anxiety. During observed wound care for a left thigh wound, the RN used the same area of gauze for multiple cleansing strokes instead of a clean gauze for each stroke, despite the facility policy requiring a clean gauze for each cleansing stroke. The DON stated staff would be expected to use a clean gauze with each cleansing stroke.
The facility failed to maintain sanitary conditions in the kitchen and dining areas, risking cross-contamination and food-borne illness for all residents. Observations revealed unsanitary conditions, including debris, oily film buildup, and splattered food debris. Dietary aides did not follow proper hygiene practices, and the dry food storage room was in disrepair. The Dietary Manager and Administrator acknowledged these issues, and the Maintenance Director admitted to a lack of deep cleaning and cleaning logs.
The facility failed to provide written transfer/discharge notices to three residents and/or their responsible parties, as required by policy. This included missing documentation for multiple hospital transfers and incomplete information on appeal rights. Nurses were responsible for notices, but the Social Service Designee was unaware of this duty.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives during hospital transfers. Three residents were affected, with no documentation of the policy being communicated. Interviews revealed that nurses were responsible for the notices, but the SSD was unaware and did not send copies to families or representatives.
A facility failed to provide necessary care for a resident with psoriasis, lacking a treatment order and consistent documentation of the skin condition. Observations showed the resident had scaly patches and scratches, and staff interviews revealed confusion about treatment orders and inadequate documentation.
The facility failed to monitor the elopement prevention wander guard system for two residents, leading to one resident being found outside and another attempting to exit. Both residents had diagnoses related to dementia, and their care plans did not adequately address the use of wander guards. Staff interviews revealed a lack of clarity and documentation regarding the monitoring and maintenance of the system.
The facility failed to ensure proper catheter care and documentation for two residents, leading to deficiencies in their care. A resident had a catheter inserted without a physician's order, and observations showed improper placement of the catheter drainage bag. Another resident lacked a physician's order for a Foley catheter, which was removed after contacting the physician. Observations indicated inadequate care, with wet clothing and sheets and the call light out of reach. Interviews with staff highlighted the absence of necessary orders and adherence to facility policies.
The facility failed to obtain physician's orders for oxygen therapy for two residents with significant medical conditions requiring respiratory support. Both residents were observed receiving oxygen without documented orders, and their care plans indicated the need for continuous oxygen therapy. Staff interviews confirmed the expectation of having physician's orders, revealing a systemic issue in obtaining and documenting necessary medical orders.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 50% error rate for three residents. Medications were left unattended, and residents self-administered without supervision or proper orders. Staff confirmed that medications should not be left with residents, and self-administration requires assessment and orders.
The facility failed to securely store medications, with multiple instances of medication carts left unlocked and unattended. On several occasions, staff members walked past these carts without securing them, while residents moved nearby. Interviews confirmed that carts should be locked when unattended, but the facility lacked a policy on medication storage.
The facility failed to maintain proper infection control practices during resident care, including incontinent care, wound care, and medication administration. Staff did not consistently perform hand hygiene or change gloves between tasks, and enhanced barrier precautions were not followed for residents requiring them. Additionally, shared medical equipment was not properly disinfected between uses, increasing the risk of infection spread.
Care plans not updated after repeated resident falls
Penalty
Summary
The facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents out of 18 sampled residents. The facility policy titled, Care Plan Review, stated that each resident should have an updated person-centered comprehensive care plan developed and implemented to address medical, physical, mental, and psychological needs, and that care plans are to be reviewed quarterly and as the resident's condition changes. Review of the records showed that Resident #67 had diagnoses including Alzheimer's disease, dementia, COPD, and major depressive disorder, and the facility's Matrix identified the resident as having falls. The resident experienced multiple falls, including unwitnessed falls with skin tears and a raised area on the forehead, as well as witnessed falls with no injury, but the care plan revised 12/04/25 did not address falls. Resident #87 had diagnoses of type II DM, COPD, and major depressive disorder, and the facility's Matrix also identified the resident as having falls. The resident had multiple unwitnessed falls, including falls with an abrasion to the shoulder and a large raised area above the eye, yet the care plan revised 10/27/25 only referenced one fall on 03/09/25 when the resident slid out of the wheelchair and Dysem was applied to the wheelchair seat. Observations showed fall mats placed by the beds, and the bed was not always in the lowest position for Resident #87. During interviews, the MDS Coordinator, ADON, DON, and Administrator stated that after a fall, the care plan should be updated with fall interventions and safety measures.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident with chronic pain, severe dementia, a sacral/coccyx wound, and a left leg wound. The resident was nonverbal and unable to report pain, and the baseline care plan noted use of acetaminophen and non-pharmacological interventions. The physician’s orders included acetaminophen as needed, wound treatments, and later hydrocodone/acetaminophen 5/325 mg every 6 hours as needed with instructions to give before treatment and incontinent care. During multiple observations of catheter, incontinent, and wound care, the resident repeatedly moaned, showed facial grimacing, and attempted to push the mattress away from the coccyx area or reach for staff hands while care was being provided. On one occasion, the resident lay on his/her side moaning and grimacing for 12 minutes while waiting for wound care to begin. Staff members involved in the care stated they believed the resident was in pain during these episodes, and one CNA reported the resident had yelled out in pain during care since admission and that staff had been trained to report non-verbal pain cues such as facial grimacing and grabbing staff. The DON stated she had just contacted the physician regarding the resident’s pain and that she had not personally assessed the wound or been aware the resident was in pain. The physician had not assessed the wound during rounds, and staff reported they were not aware that hydrocodone/acetaminophen could be given before care. The DON later stated she would expect staff to report non-verbal pain cues such as combativeness, facial grimacing, and pushing staff away during care and treatment.
Unlabeled and Expired Medications in Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted practices in two medication carts. On the A Hall medication cart for Resident #3, surveyors observed one opened bottle of Rybelus, one opened bottle of prednisolone eye drops, and one opened bottle of fluticasone propionate nasal spray that were not labeled. The same cart also contained one card with five tablets of Bactrim DS with an expiration date of 11/09/25. On the B Hall medication cart for Resident #36, surveyors observed two cards of hydroxyzine 25 mg with expiration dates of 05/25/25 and 07/25/25, two cards of dicyclomine 10 mg with expiration dates of 08/25/25 and 11/24/25, one opened bottle of ciclopriox 8% solution with an expiration date of 5/25/25, and one opened bottle of Active liquid protein that was not dated. The facility policy titled Medication Storage, dated October 2017, stated that all medications must be clearly labeled with the resident name, drug name, strength, dosage, directions, and expiration date, and that any multi-dose vials or solutions, once opened, must be dated and initialed and discarded within 28 days unless the manufacturer specifies otherwise. During interview, a CMT said expired medications should be removed from the cart and disposed of, and that staff sometimes labeled the box instead of the actual medication so the expiration date could not be seen. An LPN said expired medications should be properly disposed of and opened bottles should have the opened date written visibly. The DON said she would expect expired medications to be disposed of and for a resident not to receive an expired medication.
Infection Control Failure During Wound Care
Penalty
Summary
The facility failed to follow infection control protocols during wound care for one resident with diagnoses of cerebral infarction, vascular dementia, dysphagia, and anxiety. The resident had an order to cleanse and apply Medi-honey to a wound on the left upper thigh and cover it with bordered foam daily and as needed. During observation of the wound care, the RN performed hand hygiene, donned a gown and gloves, and placed a barrier on the bedside table with supplies on top of it, but then used gauze soaked with normal saline to clean the wound by wiping the wound three times with the same area of the gauze before discarding it. The RN then picked up a clean gauze soaked in normal saline and again wiped the wound three times with the same area of the gauze before discarding it. After removing gloves and performing hand hygiene, the RN put on clean gloves and completed the ordered wound care. The facility policy for dressings required using a clean gauze for each cleansing stroke. The DON stated staff would be expected to use a clean gauze with each cleansing stroke, and the RN stated he/she used multiple gauze to cleanse the wound and disposed of the gauze after each cleansing stroke.
Sanitation and Hygiene Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, which increased the risk of cross-contamination and food-borne illness for all 73 residents. Observations revealed multiple instances of unsanitary conditions, including scattered debris below the food preparation table, oily film buildup on food bins, and splattered food debris on walls. The walk-in refrigeration unit had a black substance on the shelving and standing water on the floor. Additionally, there were damaged wall sections and missing wall boards with exposed plumbing pipes, and a fan with an oily film blowing into the dishwashing area. Further observations showed that dietary aides did not adhere to proper hygiene practices. One aide was seen preparing food without a proper restraint for exposed facial and chest hair, and another aide repeatedly failed to perform hand hygiene while handling cups and serving drinks to residents. The facility's policies required hairnets and proper hygiene, but these were not followed, as confirmed by interviews with the Dietary Manager and the Administrator. The Maintenance Director also acknowledged the lack of deep cleaning and the absence of cleaning logs for kitchen appliances. The dry food storage room was also found to be in disrepair, with a peeled vinyl cove baseboard, frost buildup in a milk cooler, and an unfinished ceiling repair area. Light fixtures were either uncovered or damaged. The Dietary Manager and Administrator both acknowledged the deficiencies, noting that the kitchen and storage areas should be clean and in good repair, and that staff should follow hygiene protocols. The Maintenance Director admitted to overseeing cleaning but did not keep logs, and was unaware of some of the issues present in the storage area.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to three residents and/or their responsible parties, as required by their policy. The policy mandates a 30-day written notice for transfers or discharges, except in urgent situations where notice should be given as soon as practicable. However, for Resident #32, #37, and #60, there was no documentation of written notification for multiple hospital transfers. This includes the absence of reasons for the transfers and the necessary appeal rights information. Additionally, the facility's documentation for Resident #60's transfer on 06/26/24 was incomplete, lacking critical information such as the right to appeal, contact details for the state entity handling appeals, and guidance on requesting an appeal hearing. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that nurses were responsible for completing transfer/discharge notices and contacting families and physicians. However, the Social Service Designee was unaware of these notices and did not provide copies to families or representatives.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents out of four sampled, with a facility census of 73. The facility's undated Bed-Hold Policy did not include a provision for providing a written copy to the resident or their representative. Specifically, Resident #32 was transferred to the hospital on two occasions without documentation of the bed-hold policy being provided. Similarly, Resident #37 was transferred to the hospital and remained there without receiving the required notification. Resident #60 experienced multiple hospital transfers, yet there was no documentation of the bed-hold policy being communicated in writing on any of these occasions. Interviews conducted during the investigation revealed a lack of awareness and responsibility among the facility staff regarding the bed-hold notices. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) indicated that nurses were responsible for completing the bed-hold notices. However, the Social Services Designee (SSD) was unaware of the notices and did not send copies to the family, representative, or guardians. This lack of communication and documentation led to the deficiency in providing the necessary written notifications to the residents and their representatives.
Failure to Provide Adequate Skin Condition Treatment
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for a resident with a skin condition. The resident, who had diagnoses of psoriasis, stroke, and aphasia, was admitted with an order for weekly skin observations but lacked an order for psoriasis treatment. The care plan indicated the need for ongoing evaluations and interventions to prevent skin breakdown, including the application of creams. However, the Treatment Administration Records showed inconsistent documentation of the resident's skin condition, with several instances where the skin was noted as red but lacked detailed descriptions or interventions. Observations over several days revealed the resident had scaly, crusted patches and scratches on the face, indicating a psoriasis flare-up. Interviews with staff revealed that the resident sometimes refused treatment, and there was confusion about the existence of a psoriasis medication order. The Assistant Director of Nursing acknowledged the absence of documentation addressing the skin abnormality in the progress notes or skin alert, highlighting a lapse in the facility's care and documentation practices.
Failure to Monitor Elopement Prevention System
Penalty
Summary
The facility failed to provide a safe environment by not adequately monitoring the elopement prevention wander guard system for two residents. Resident #62, who was admitted with diagnoses of dementia and major depressive disorder, was found outside in the parking lot after leaving his wheelchair inside, which prevented the door alarm from sounding. The resident's care plan did not address the elopement risk with individualized interventions or the continued use of an alarm/wander guard, despite the resident's history of making statements about leaving. Resident #70, admitted with vascular dementia and metabolic encephalopathy, attempted to exit the building at the front entrance. Although a wander guard was placed on the resident, the care plan did not address the use of the wander guard. Observations showed the resident moving around the facility with the wander guard on, but there was no documentation that the wander guard alarms were checked for placement, function, and expiration date every shift. Interviews with facility staff revealed a lack of clarity and documentation regarding the monitoring and maintenance of the wander guard system. LPN K mentioned that the night shift was responsible for checking the wander guards, but was unsure if the checks were done or documented. The ADON and CMT M also expressed uncertainty about the monitoring process, and the Administrator admitted that maintenance checked the wander guard bracelets and doors but was unsure of the frequency. The facility's policy was not followed as there was no documentation of the checks being performed.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper catheter care and documentation for two residents, leading to deficiencies in their care. Resident #10, who was admitted with diagnoses including heart failure and spinal stenosis, had a catheter inserted without a physician's order for the catheter or its care. Observations revealed that the catheter drainage bag was frequently placed on the floor or above the bladder, contrary to facility policy, which requires the bag to be kept lower than the bladder to prevent backflow. Interviews with staff confirmed the lack of proper orders and understanding of catheter care protocols. Resident #28, admitted with conditions such as hemiplegia and morbid obesity, also lacked a physician's order for a Foley catheter, which was placed at the hospital prior to admission. The catheter was removed after the facility contacted the physician due to the absence of a related diagnosis. Observations showed the resident lying in bed with wet clothing and sheets, and the call light was out of reach, indicating inadequate care and response to the resident's needs. Interviews with nursing staff, including the Director of Nursing and Assistant Director of Nursing, highlighted the absence of necessary orders for catheter placement and care. The staff acknowledged the need for such orders and the importance of maintaining the catheter drainage bag below the bladder level. These deficiencies in catheter care and documentation reflect a failure to adhere to established facility policies and procedures, compromising the quality of care provided to the residents.
Failure to Obtain Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order for oxygen was obtained for two residents, both of whom had significant medical conditions requiring respiratory support. Resident #10, diagnosed with heart failure, was observed receiving oxygen therapy without a corresponding physician's order. The resident's medical records, including the Minimum Data Set and Physician Order Sheet, did not document any order for oxygen therapy. Observations on multiple occasions showed the resident using oxygen at varying levels, with the oxygen tubing and humidifier canister not dated, indicating a lack of adherence to the facility's policy on oxygen administration. Similarly, Resident #43, with diagnoses including heart failure, COPD, emphysema, and cardiomyopathy, was also receiving oxygen therapy without a documented physician's order. The resident's care plan indicated the need for continuous oxygen therapy, yet the August 2024 Physician Order Sheet lacked any orders for oxygen or tubing changes. Observations revealed the resident using oxygen at different flow rates, with undated tubing and an empty humidifier canister. Interviews with staff confirmed the expectation of having a physician's order for oxygen therapy, highlighting a systemic issue in obtaining and documenting necessary medical orders for residents requiring respiratory care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 50% error rate for three residents. The errors were identified through observation, interview, and record review. The facility's policy required staff to remain with residents until medications were swallowed, but this was not adhered to in several instances. Resident #43 was observed with a Spiriva inhaler at the bedside, which was used without staff supervision. There was no documentation of education or assessment for self-administration, and the care plan did not address this. The resident confirmed that staff left the inhaler for self-use, contrary to facility policy. Resident #48's medications were mixed into applesauce and left unattended, with the resident consuming them without direct supervision. Similarly, Resident #179's medications were placed in a cup and left on the bedside table without supervision. Interviews with staff confirmed that medications should not be left unattended, and residents should not self-administer without proper orders and assessments.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
The facility failed to store medications securely, as observed on multiple occasions where medication carts were left unlocked and unattended. On 08/19/24, the 60 Hall medication cart was left unlocked at various times between 9:37 A.M. and 1:06 P.M., with staff members walking past it without securing it. During this period, residents were observed moving past the unattended cart, which contained a nystatin bottle left on top. Similarly, the A Wing treatment cart was found unlocked and unattended at 1:06 P.M., until it was locked by the MDS Coordinator at 1:10 P.M. Further observations on 08/21/24 revealed that CMT E left the medication cart unlocked and unattended at 8:18 A.M., returning a minute later to continue the medication pass. Interviews with staff, including CMT F, CMT E, RN A, the Administrator, and the DON, confirmed that medication and treatment carts should be locked when unattended. However, the facility did not provide a policy regarding the storage of medication, contributing to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during various care activities, including incontinent care, wound care, and medication administration. Observations revealed that staff did not consistently perform hand hygiene or change gloves between different care tasks, particularly when transitioning from dirty to clean care areas. For instance, during incontinent care for several residents, staff members were observed not washing their hands or changing gloves after handling soiled materials and before touching clean areas or equipment. This lack of adherence to infection control protocols was noted across multiple instances and involved several staff members. Additionally, the facility did not follow enhanced barrier precautions (EBP) for residents who required them due to conditions such as chronic wounds or indwelling medical devices. Staff failed to wear appropriate personal protective equipment (PPE), such as gowns, during high-contact care activities, which are necessary to prevent the transmission of multidrug-resistant organisms. This was observed during the care of residents with specific medical needs, where the required precautions were not implemented, increasing the risk of infection spread. The facility also neglected to properly disinfect shared medical equipment, such as glucometers, between uses on different residents. This was observed during medication administration, where staff did not clean the glucometer after each use, nor did they perform hand hygiene between residents. These lapses in infection control practices were acknowledged by staff during interviews, indicating a systemic issue with adherence to established protocols and policies designed to prevent infection transmission within the facility.
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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 Poplar Bluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedargate Health Care Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Manor, The | 4.1 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Poplar Bluff | 4.2 mi | ★★★★★ | 2 | 0 |
| Oakdale Care Center | 4.7 mi | ★★★★★ | 9 | 0 |
| Puxico Nursing And Rehabilitation Center | 22.3 mi | ★★★★★ | 5 | 0 |
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