6 Reports
Inspection Report — Jun 7, 2024
Routine
Date: Jun 7, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The survey cited 3 federal health deficiencies concerning facility cleanliness/environment, medication storage practices, and resident record confidentiality, and 5 Missouri state deficiencies addressing the medication system, floor surfaces, walls/ceilings, toilet room requirements, and medical record confidentiality.
Deficiencies (5)
19 CSR 30-85.042(46) Safe/Effective Medication System: Please refer to F761.
19 CSR 30-87.020(12) Floor Surfaces: Please refer to F584.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Please refer to F584.
19 CSR 30-87.020(41) Toilet Room Requirements: Please refer to F584.
19 CSR 30-88.010(28) Med Record Confidential, Written Consent: Please refer to F842.
Report Facts
residents affected: 6
Inspection Report — Mar 15, 2024
Complaint Investigation
Date: Mar 15, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) are present; the file cites complaint/investigation numbers MO00232685 and MO00232774.
Complaint Details
MO00232685 and MO00232774 are cited in the file; the forms do not state whether the allegations were substantiated.
Findings
Two deficiencies were cited: one federal health-tag for failure to obtain/document resident consent and provide written notice for a room change, and one Missouri state licensure citation for resident room transfer (Class II*) that refers to the federal finding.
Deficiencies (1)
19 CSR 30-88.010(19) Resident Room Transfer: Please refer to F559.
Inspection Report — Sep 29, 2023
Routine
Date: Sep 29, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two federal health deficiencies were cited related to quality of care (failure to document a fall and complete post-fall monitoring) and free of accident hazards/supervision (wandering and wanderguard alarm response). Three Missouri State deficiencies were cited related to protective oversight/voluntary leave, nursing care per resident condition, and progress notes/change in condition.
Deficiencies (3)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Please refer to F689.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Please refer to F684.
19 CSR 30-85.042(99)(B) Progress Notes - change in condition: Please refer to F684.
Report Facts
Provider/Supplier/CLIA identification number: 265877
State provider/facility identification number: 31754
Inspection Report — Jul 21, 2022
Routine
Date: Jul 21, 2022
Visit Reason
Federal health survey (CMS-2567) with an accompanying Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 12 federal health deficiencies and 12 Missouri state licensure deficiencies addressing resident personal care and hygiene, background checks and employee registry checks, transfer/notice procedures, care plans and ADLs, activity programming, medication safety and infection control, bedrail assessments and consents, food safety and labeling, medical record documentation (including ostomy/wound vac), resident call systems, and resident fund bonding.
Deficiencies (12)
19 CSR 30-85.012(124) Nurses' Call System Requirements: Please refer to F919.
19 CSR 30-85.042(17) Criminal Background Check Request: Please refer to F607.
19 CSR 30-85.042(46) Safe/Effective Medication System: Please refer to F684.
19 CSR 30-85.042(50) Self-Administration of Medication: Please refer to F684.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Please refer to F700.
19 CSR 30-85.042(67) Clean, Dry, Odor Free: Please refer to F561 and F677.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Please refer to F880.
19 CSR 30-85.042(92) Activity Program: Please refer to F679.
19 CSR 30-85.042(102) Clinical Records Accurate/Accessible: Please refer to F842.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.
19 CSR 30-87.030(84) Equip/Utensils Air Dried, Self-Drain Utensils: Please refer to F812.
19 CSR 30-88.020(14) Resident Fund Bond Requirements: Please refer to F919.
Report Facts
residents affected: 9
residents affected: 2
residents sampled: 23
residents affected: 5
bond amount (USD): 47000
bond amount (USD): 52500
Inspection Report — Jul 21, 2022
Life Safety
Date: Jul 21, 2022
Visit Reason
CMS federal Statement of Deficiencies (health and life safety) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Twelve deficiencies were cited: seven federal life safety/emergency preparedness deficiencies concerning emergency preparedness planning, egress/locking arrangements, fire alarm testing, sprinkler maintenance, fire department connection signage, smoke barrier penetrations, smoking regulations, and generator load testing; and five Missouri state licensure deficiencies mirroring fire alarm, sprinkler, door locks, smoke section walls/doors, and ashtray/disposal requirements.
Deficiencies (5)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Please refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Please refer to K353.
19 CSR 30-85.022(16) Door Locks: Please refer to K222.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Please refer to K372.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Please refer to K741.
Inspection Report — Mar 16, 2022
Complaint Investigation
Date: Mar 16, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (complaint numbers MO00198006 and MO00197504).
Complaint Details
Complaint numbers MO00198006 and MO00197504; substantiation not stated in the record.
Findings
Five deficiencies were cited: three federal deficiencies addressing misappropriation/exploitation, failure to report alleged violations, and failure to investigate/prevent/correct alleged violations; and two Missouri state deficiencies addressing safe/effective medication system and development/implementation of abuse/neglect policies.
Deficiencies (2)
19 CSR 30-85.042(46) Safe/Effective Medication System: Please refer to F602, see all examples.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F609. Please refer to F610.
Report Facts
residents affected: 3
residents affected: 2
20 CMS Surveys
Inspection Report — Jan 14, 2026
Complaint Investigation
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 — Jul 1, 2025
Complaint Investigation
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
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 — Dec 31, 2024
Routine
Date: Dec 31, 2024
Visit Reason
Federal health survey (CMS-2567); the survey type is not stated in the document.
Findings
One federal health deficiency was cited for pharmacy services/medication recordkeeping related to controlled substances and inaccurate narcotic counts. Past noncompliance was noted.
Deficiencies (1)
F 755 Pharmacy Srvcs/Procedures/Pharmacist/Records: Based on interview and record review, the facility failed to establish a system of record keeping to ensure all controlled substances were accurately accounted for. Staff did not accurately document administrations and could not reconcile the balance of a controlled medication for one resident out of four sampled residents.
Report Facts
residents sampled: 4
Inspection Report — Jun 7, 2024
Routine
Date: Jun 7, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The survey cited 3 federal health deficiencies concerning facility cleanliness/environment, medication storage practices, and resident record confidentiality, and 5 Missouri state deficiencies addressing the medication system, floor surfaces, walls/ceilings, toilet room requirements, and medical record confidentiality.
Deficiencies (3)
F 584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to ensure a clean, homelike environment; multiple residents' shared bathrooms were observed with brown fecal-like matter, urine-like odor, dirty walls and mirrors, debris on floors, and the facility lacked a policy related to cleaning and maintaining resident bathrooms.
F 761 Label/Store Drugs and Biologicals: Staff prepared medications and placed medication cups in the top drawer of an unlocked medication cart and walked away, leaving medications out of view and not stored per standards of practice.
F 842 Resident Records - Identifiable Information: Staff left a computer on the medication cart unlocked and unattended, making resident-identifiable medical information visible to others.
Report Facts
residents affected: 6
Inspection Report — Jun 7, 2024
Life Safety
Date: Jun 7, 2024
Visit Reason
This file contains a CMS-2567 Life Safety survey (K/E pages) and a Missouri Department of Health and Senior Services State Form licensure inspection; the Life Safety initial comments reference the Life Safety Code. No complaint numbers are stated.
Findings
No deficiencies were cited on the CMS-2567 Life Safety portion and no state licensure deficiencies were cited on the Missouri State Form.
Inspection Report — Mar 15, 2024
Complaint Investigation
Date: Mar 15, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) are present; the file cites complaint/investigation numbers MO00232685 and MO00232774.
Complaint Details
MO00232685 and MO00232774 are cited in the file; the forms do not state whether the allegations were substantiated.
Findings
Two deficiencies were cited: one federal health-tag for failure to obtain/document resident consent and provide written notice for a room change, and one Missouri state licensure citation for resident room transfer (Class II*) that refers to the federal finding.
Deficiencies (1)
F559 Choose/Be Notified of Room/Roommate Change: Based on interview and record review, the facility failed to ensure residents' right to share a room with his or her roommate of choice and the right to receive written notice of the room change, including the reason, were protected when staff moved one resident to a room on a different hall without a written notice issued or documentation of the resident's consent to the change.
Inspection Report — Sep 29, 2023
Routine
Date: Sep 29, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two federal health deficiencies were cited related to quality of care (failure to document a fall and complete post-fall monitoring) and free of accident hazards/supervision (wandering and wanderguard alarm response). Three Missouri State deficiencies were cited related to protective oversight/voluntary leave, nursing care per resident condition, and progress notes/change in condition.
Deficiencies (2)
F684 Quality of Care: The facility failed to provide care in accordance with standards when staff failed to document a fall or complete post-fall monitoring for one resident, resulting in a possible delay in identifying a hip fracture.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure all residents received adequate supervision to prevent possible accidents when staff failed to respond to an alarm and to have a process and training to routinely check wanderguard devices, contributing to elopement and injury for residents.
Report Facts
Provider/Supplier/CLIA identification number: 265877
State provider/facility identification number: 31754
Inspection Report — Jul 21, 2022
Routine
Date: Jul 21, 2022
Visit Reason
Federal health survey (CMS-2567) with an accompanying Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 12 federal health deficiencies and 12 Missouri state licensure deficiencies addressing resident personal care and hygiene, background checks and employee registry checks, transfer/notice procedures, care plans and ADLs, activity programming, medication safety and infection control, bedrail assessments and consents, food safety and labeling, medical record documentation (including ostomy/wound vac), resident call systems, and resident fund bonding.
Deficiencies (12)
F561 Self-Determination: The facility failed to provide showers as preferred for nine residents.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to complete required criminal background checks/registry (FCSR, CBC, EDL, NA Registry) for multiple staff.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the resident and the resident's representative in writing of a hospital transfer for two residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for multiple residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure two residents received showers/baths as needed to maintain good personal hygiene.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide scheduled weekend activities and the activity room/activities for the specialized care unit were not accessible as expected.
F684 Quality of Care: The facility failed to ensure appropriate safe medication administration when staff left medication at the bedside of one resident.
F700 Bedrails: The facility failed to document pre-use assessments, obtain informed consent, and obtain physician orders for the use of bed rails for multiple residents and failed to document care planning for side rail use for others.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to keep food safe from potential contamination when food contact surfaces (dishes) were stacked wet instead of air-dried and failed to date/label opened food items in refrigerators/freezers.
F842 Resident Records - Identifiable Information: The facility failed to ensure staff accurately documented colostomy care and failed to properly document wound vac/tubing and dressing use for one resident.
F880 Infection Prevention & Control: The facility failed to follow infection control and hand hygiene procedures during personal care and medication preparation/administration for multiple residents.
F919 Resident Call System: The facility's call light system was not adequately available when emergency call pull cords in resident bathrooms were wrapped around grab bars so residents could not access them.
Report Facts
residents affected: 9
residents affected: 2
residents sampled: 23
residents affected: 5
bond amount (USD): 47000
bond amount (USD): 52500
Inspection Report — Jul 21, 2022
Life Safety
Date: Jul 21, 2022
Visit Reason
CMS federal Statement of Deficiencies (health and life safety) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Twelve deficiencies were cited: seven federal life safety/emergency preparedness deficiencies concerning emergency preparedness planning, egress/locking arrangements, fire alarm testing, sprinkler maintenance, fire department connection signage, smoke barrier penetrations, smoking regulations, and generator load testing; and five Missouri state licensure deficiencies mirroring fire alarm, sprinkler, door locks, smoke section walls/doors, and ashtray/disposal requirements.
Deficiencies (7)
E004 Develop EP Plan, Review and Update Annually: Based on observation, interview, and record review, the facility failed to perform the required yearly review of the Emergency Operations Plan; EOP binders lacked an initial date, had outdated staff contact information, and the plan had not been recently reviewed.
K222 Egress Doors: The facility failed to ensure two egress doors equipped with fifteen (15) second delayed-egress locking arrangements had appropriate signage located on the door leaf adjacent to the release device in the direction of egress; signage was missing and staff were unaware of requirements.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to document smoke detector sensitivity testing for the past two years.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler heads in the attic were unobstructed and failed to ensure fire department connection signage was present; insulation covered sprinkler heads and the fire department connection sign was missing.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain the smoke resistive properties of smoke barrier walls; multiple penetrations and unsealed conduits/ gaps were observed in the smoke barrier walls.
K741 Smoking Regulations: The facility failed to properly maintain smoking areas, with multiple cigarette butts and ash present in trash and no appropriate metal self-closing ashtray containers observed.
K918 Electrical Systems - Essential Electric System: The facility failed to complete a required four-hour generator load test within the past three years.
Inspection Report — Mar 16, 2022
Complaint Investigation
Date: Mar 16, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (complaint numbers MO00198006 and MO00197504).
Complaint Details
Complaint numbers MO00198006 and MO00197504; substantiation not stated in the record.
Findings
Five deficiencies were cited: three federal deficiencies addressing misappropriation/exploitation, failure to report alleged violations, and failure to investigate/prevent/correct alleged violations; and two Missouri state deficiencies addressing safe/effective medication system and development/implementation of abuse/neglect policies.
Deficiencies (3)
F602 Free from Misappropriation/Exploitation CFR(s): 483.12: Based on interview and record review, the facility failed to protect residents from misappropriation when it could not account for narcotic medications delivered and stored for Residents #1, #2, and #3.
F609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4): The facility failed to report allegations of misappropriation of medications for two residents to the Department of Health and Senior Services within 24 hours as required.
F610 Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12 (c)(2)-(4): The facility failed to document a full investigation of allegations of misappropriation for two residents and failed to report investigative findings to the State Survey Agency within five working days.
Report Facts
residents affected: 3
residents affected: 2
Inspection Report — Jun 16, 2021
Complaint Investigation
Date: Jun 16, 2021
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Infection Control Survey and COVID-19 Focused Emergency Preparedness survey). The document states this was a complaint investigation.
Complaint Details
No deficiencies were cited on the complaint investigation; no complaint number is provided in the document.
Findings
No deficiencies were cited on this complaint investigation; the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report — Mar 3, 2021
Routine
Date: Mar 3, 2021
Visit Reason
Federal CMS-2567 health and emergency preparedness survey. The Initial Comments state this was a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey.
Findings
No health or emergency preparedness deficiencies were cited; the facility was found in compliance with applicable COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Dec 2, 2020
Complaint Investigation
Date: Dec 2, 2020
Visit Reason
CMS-2567 federal survey (health and emergency preparedness initial comments); the document reports a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey and states it was a complaint investigation.
Complaint Details
No complaint number provided on the form; the form states 'No deficiencies were cited on this complaint investigation.'
Findings
No deficiencies were cited; the survey documents the facility was found in compliance with the applicable COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Oct 21, 2020
Routine
Date: Oct 21, 2020
Visit Reason
CMS-2567 federal survey; a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted as stated in the Initial Comments.
Findings
No federal health survey deficiencies were cited; the facility was found in compliance with CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report — Sep 30, 2020
Complaint Investigation
Date: Sep 30, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness survey (COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control); the file states this was a complaint investigation.
Findings
No deficiencies were cited; the surveyor found the facility in compliance with applicable COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Sep 17, 2020
Complaint Investigation
Date: Sep 17, 2020
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Infection Control Survey and COVID-19 Focused Emergency Preparedness survey); the document states it was a complaint investigation.
Findings
Zero deficiencies were cited; the survey found the facility in compliance with COVID-19 infection control and emergency preparedness practices.
Inspection Report — Sep 11, 2020
Routine
Date: Sep 11, 2020
Visit Reason
Federal CMS-2567 health survey (CMS COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control Survey) conducted on 09/11/2020.
Findings
No deficiencies were cited; initial comments state the facility was found in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS/CDC recommended practices for infection control.
Inspection Report — Jun 12, 2020
Routine
Date: Jun 12, 2020
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control Survey) as stated on the form; no complaint number is cited.
Findings
No deficiencies were cited; the facility was found in compliance with COVID-19 emergency preparedness requirements and with CMS/CDC infection control recommendations.
Inspection Report — Jul 16, 2019
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.
Inspection Report — Jul 16, 2019
Routine
Date: Jul 16, 2019
Visit Reason
CMS-2567 federal Emergency Preparedness and Life Safety pages and a Missouri state licensure (State Form) page; the survey type is not stated.
Findings
No federal health, life safety, or state licensure deficiencies were cited on this survey (0 deficiencies).
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