Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
109 residents
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Jan 14, 2026
Visit Reason
The inspection was conducted due to an allegation of physical abuse by a staff member (Certified Nursing Assistant A) against a resident (Resident #1) during toileting on 01/08/2026.
Complaint Details
Complaint #2711706. The allegation was substantiated as CNA A admitted to inappropriately touching the resident's face. The facility took immediate corrective actions including termination of CNA A and staff training.
Findings
The facility failed to protect Resident #1 from physical abuse when CNA A pushed the resident's face after being spat on. The incident was reported immediately, investigated, and corrective actions including staff training and monitoring were implemented. CNA A was terminated for the abuse.
Deficiencies (1)
Failure to protect a resident from physical abuse by staff when CNA A pushed the resident's face.
Report Facts
Residents present: 109
Date of incident: Jan 8, 2026
Date of correction: Jan 9, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Staff member who physically pushed the resident's face and was terminated |
| NA B | Nurse Aide | Staff present during the incident who assisted with toileting |
| HR | Human Resources Representative | Received report from CNA A and escorted CNA A out of the building |
| DON | Director of Nursing | Involved in investigation and interviews regarding the incident |
| Administrator | Facility Administrator | Involved in investigation and interviews regarding the incident |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
The inspection was conducted following a complaint regarding a staff member (Licensed Practical Nurse D) grabbing food away from a resident (Resident #1) and not treating the resident with dignity and respect.
Complaint Details
The complaint was substantiated based on record review, observation, and interviews indicating that LPN D improperly grabbed food from a confused resident with dementia and did not treat the resident with dignity and respect.
Findings
The facility failed to ensure all residents were treated with dignity and respect when LPN D grabbed a resident's arm and took food from the resident's hand during a meal service. Interviews with staff and review of policies confirmed that the staff action was inappropriate and contrary to facility standards.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights when LPN D grabbed food from Resident #1's hand.
Report Facts
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Licensed Practical Nurse | Named in the finding for grabbing food from Resident #1's hand |
| CNA E | Certified Nurse Aide | Interviewed regarding the incident and resident behavior |
| CNA C | Certified Nurse Aide | Interviewed regarding proper handling of residents during meal service |
| Registered Nurse A | Registered Nurse | Interviewed regarding meal service procedures and resident handling |
| Director of Nursing | Director of Nursing | Interviewed and provided statements on proper resident care and dignity |
| Administrator | Administrator | Interviewed and provided statements on resident dignity and respect |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to accurately document and reconcile controlled substances, specifically morphine sulfate, for one resident (Resident #1).
Complaint Details
The complaint investigation found discrepancies in the narcotic count for morphine sulfate starting 11/27/24, with incorrect documentation and a missing 4 ml of medication. The facility notified local law enforcement and the Department of Health and Senior Services. Interviews with nursing staff revealed procedural errors in narcotic counts and documentation. The facility corrected the noncompliance on 12/12/24.
Findings
The facility failed to establish an accurate system of record keeping for controlled substances, resulting in discrepancies in morphine sulfate documentation and a missing 4 ml of medication. The facility conducted an investigation, notified authorities, and implemented corrective actions including staff in-servicing and medication audits.
Deficiencies (1)
Failure to accurately document all administrations of and reconcile the balance of a controlled medication (morphine sulfate) for one resident.
Report Facts
Facility census: 110
Missing medication amount: 4
Date of medication discrepancy start: Nov 27, 2024
Date noncompliance corrected: Dec 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Noticed narcotic count discrepancy and reported it to ADON |
| ADON | Assistant Director of Nursing | Reviewed narcotic documentation and notified DON |
| DON | Director of Nursing Services | Notified of discrepancies and involved in investigation |
| CMT A | Certified Medication Technician | Described narcotic pass procedures and reporting |
| LPN C | Licensed Practical Nurse | Described narcotic count procedures and discrepancy handling |
| Administrator | Facility Administrator | Described narcotic count procedures and expectations |
Inspection Report
Routine
Census: 108
Deficiencies: 3
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident environment cleanliness, medication storage, and confidentiality of medical records at the nursing home facility.
Findings
The facility failed to maintain a clean and homelike environment in resident bathrooms, with multiple observations of fecal-like matter and strong odors. Additionally, the facility failed to ensure medication carts were locked when unattended and medical records were left visible on unlocked computer screens. Interviews confirmed staff expectations for proper cleaning and security practices.
Deficiencies (3)
Failed to maintain cleanliness of resident bathrooms, including fecal-like matter smeared on toilets, walls, and floors.
Failed to ensure medication carts were locked when unattended, allowing access to resident medications.
Failed to safeguard resident medical records by leaving computer screens unlocked and visible to others.
Report Facts
Residents affected: 6
Facility census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT D | Certified Medication Technician | Observed leaving medication cart unlocked and computer screen visible |
| CMT E | Certified Medication Technician | Interviewed about locking medication cart and computer screen |
| LPN J | Licensed Practical Nurse | Interviewed about locking medication cart and computer screen |
| CMT G | Certified Medication Technician | Interviewed about locking medication cart and computer screen |
| LPN K | Licensed Practical Nurse | Interviewed about locking medication cart and computer screen |
| CMT F | Certified Medication Technician | Interviewed about locking medication cart and computer screen |
| CMT H | Certified Medication Technician | Interviewed about locking medication cart and computer screen |
| Housekeeping C | Housekeeping Staff | Interviewed about cleaning procedures and responsibilities |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning procedures and expectations |
| CNA A | Certified Nurse Aide | Interviewed about housekeeping notifications |
| CNA B | Certified Nurse Aide/Activities Director | Interviewed about housekeeping responsibilities and observations |
| Administrator | Facility Administrator | Interviewed about cleaning and medication cart locking expectations |
| Director of Nursing | Director of Nursing | Interviewed about medication cart and computer screen locking expectations |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a resident's right to share a room with a roommate of choice and to receive written notice before a room change was made.
Complaint Details
The complaint involved Resident #1 being moved to a different room without written notice or documented consent. The resident was upset about the move, and the facility did not document consent or provide written notice despite verbal discussions. The family approved the move, but documentation was lacking.
Findings
The facility failed to provide written notice or document resident consent when moving Resident #1 to a different hall. Interviews and record reviews showed behavioral issues with Resident #1 and that the room change was approved by the resident's family but not properly documented. The facility lacked a written room change notice or consent form.
Deficiencies (1)
Failed to ensure residents' right to share a room with roommate of choice and to receive written notice before a room change.
Report Facts
Census: 105
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Spoke with resident and family regarding room change; responsible for documenting room change and consent |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Spoke with resident regarding room change; involved in decision-making |
| Administrator | Administrator | Responsible for room changes; involved in decision-making |
| Registered Nurse E | Registered Nurse (RN) | Reported resident behaviors and involvement in room change |
| Certified Nurses Assistant A | Certified Nurses Assistant (CNA) | Reported resident's reaction to room change |
| Certified Medication Technician B | Certified Medication Technician (CMT) | Reported on room change process |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Reported on room change process |
| Director of Nursing | Director of Nursing (DON) | Involved in decision-making regarding room change |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate care after a resident fall resulting in a hip fracture, and failure to ensure adequate supervision and monitoring of residents with wanderguard devices to prevent elopement and injury.
Complaint Details
The complaint investigation revealed that Resident #3 had a fall on 09/02/23 that was not documented or monitored, leading to a delayed diagnosis of a left hip fracture on 09/06/23. Additionally, Resident #1 eloped from the facility on 09/28/23 after wanderguard alarms were not properly responded to, resulting in injury. The facility lacked proper procedures and staff training for wanderguard device monitoring and response to alarms.
Findings
The facility failed to document and monitor a resident's fall leading to a delayed identification of a hip fracture, and failed to ensure adequate supervision and response to wanderguard alarms for two residents, resulting in one resident eloping and sustaining injury. The facility also lacked a process for regular inspection and verification of wanderguard devices worn by residents.
Deficiencies (2)
Failure to provide care in accordance with standards when staff failed to document a fall or complete post fall monitoring for one resident resulting in possible delay of injury identification.
Failure to ensure all residents received adequate supervision to prevent accidents, including failure to respond to wanderguard alarms and lack of staff training on wanderguard device monitoring.
Report Facts
Facility census: 101
Fall date: Sep 2, 2023
Fracture identification date: Sep 6, 2023
Resident admission date: May 1, 2019
Resident admission date: Mar 22, 2023
Wanderguard inspection dates: Array
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Named in failure to document fall and post-fall monitoring for Resident #3 |
| LPN D | Licensed Practical Nurse | Charge nurse during Resident #1 elopement incident; silenced wanderguard alarm without verifying resident location |
| LPN E | Licensed Practical Nurse | Charge nurse during Resident #1 elopement incident; involved in wanderguard alarm response |
| CNA I | Certified Nursing Assistant | Witnessed Resident #3 fall and notified LPN L |
| CNA F | Certified Nursing Assistant | Responded to Resident #1 elopement and assisted in return |
| CNA G | Certified Nursing Assistant | Responded to Resident #1 elopement and assisted in return |
| CNA H | Certified Nursing Assistant | Responded to Resident #1 elopement and assisted in return |
| RN O | Registered Nurse | Provided interview on fall reporting and documentation procedures |
| DON | Director of Nursing | Provided interview on fall and wanderguard alarm policies |
| Administrator | Facility Administrator | Provided interview on fall and wanderguard alarm policies |
| Regional Nurse Consultant | Provided interview on facility policies and wanderguard alarm procedures | |
| Maintenance Director | Maintenance Director | Responsible for wanderguard system checks but not device inspections |
Inspection Report
Routine
Census: 89
Deficiencies: 11
Date: Jul 21, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, staff background checks, notification of transfers, care planning, bathing and hygiene, medication administration, use of bed rails, food safety, infection control, and call light system functionality.
Findings
The facility was found deficient in multiple areas including failure to provide showers as preferred for nine residents, incomplete staff background checks, failure to notify residents and representatives of hospital transfers in writing, incomplete and non-comprehensive care plans for residents with complex needs, inadequate bathing and hygiene assistance for some residents, unsafe medication administration practices including leaving medications at bedside, lack of informed consent and documentation for bed rail use, improper food storage and labeling, inaccurate documentation of colostomy care and wound vac orders, failure to follow hand hygiene protocols during care and medication administration, and malfunctioning call light cords in resident bathrooms.
Deficiencies (11)
Failed to provide showers as preferred for nine residents, with residents reporting long intervals without showers and lack of a shower schedule.
Failed to complete required criminal background checks, Family Care Safety Registry checks, Employee Disqualification List checks, and Nurse Aide Registry checks for multiple staff.
Failed to notify residents and their representatives in writing of hospital transfers for two residents.
Failed to develop and implement comprehensive person-centered care plans for three residents, lacking measurable objectives and documentation of care needs such as ostomy and feeding tube care.
Failed to provide adequate bathing and hygiene assistance to two residents, resulting in poor personal hygiene and skin condition.
Left medication at the bedside of one resident for self-administration without staff supervision, contrary to facility policy and standards.
Failed to document pre-use assessment, obtain informed consent, and obtain physician orders for use of bed rails for five residents; care plans lacked documentation of side rail use.
Failed to keep food safe from potential contamination by stacking wet dishes and failing to label or date opened food items in refrigerators and freezer.
Failed to accurately document colostomy care for one resident and continued to document wound vac care that was not provided for the resident.
Failed to follow infection control guidelines related to hand hygiene during personal care for two residents and medication administration for five residents.
Call light cords in multiple resident bathrooms were wrapped around grab bars, restricting residents' ability to activate call lights for assistance.
Report Facts
Residents affected by bathing deficiency: 9
Facility census: 89
Staff missing background checks: 10
Residents affected by call light deficiency: 89
Residents affected by bed rail deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT L | Certified Medication Technician | Left medication at bedside for Resident #13; observed not performing hand hygiene during medication administration |
| LPN P | Licensed Practical Nurse | Observed not performing hand hygiene during medication and tube feeding administration |
| CNA H | Certified Nurse Aide | Observed failing to perform hand hygiene during perineal care for Resident #51 |
| Assistant Director of Nursing | ADON | Reported no shower schedule and no dedicated shower aide |
| Director of Nursing | DON | Reported staff should not leave medications at bedside and emphasized hand hygiene |
| Certified Dietary Manager | CDM | Unaware dishes were being put away wet; discarded unlabeled food items |
| Licensed Practical Nurse G | LPN | Reported colostomy care should be charted and wound vac order discontinued |
| Physical Therapy Aide F | PTA | Did not complete evaluation or consent for bed rail use |
| Administrator | Acknowledged deficiencies in call light system and medication administration practices |
Inspection Report
Deficiencies: 0
Date: Jul 16, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for the nursing home Westgate, summarizing the results of a regulatory survey completed on 07/16/2019.
Findings
No health deficiencies were found during the inspection.
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