MissouriKansas City

Bridgewood Health Care Center

11515 Troost, Kansas City, MO 64131 · Jackson County · 166 certified beds · avg 134 residents/day · certified since Aug 28, 2008

Abuse citation flag (CMS)SFF Candidate

Part of chain: RELIANT CARE MANAGEMENT (34 facilities, chain avg rating 1.2★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
26
Serious findings on record
$1,148,689
Fines, last 3 years
2.26
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Apr 14, 2026 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: May 25, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Mar 12, 2026 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Apr 12, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Nov 25, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Nov 26, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Mar 5, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Mar 10, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Jan 31, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Mar 10, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Nov 15, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Nov 5, 2024 (Past Non-Compliance)

▲ Immediate jeopardy, one-off · Sep 12, 2024 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Oct 27, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Jun 25, 2024 · F-0584 · triggered by a complaint

The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.

Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 25, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · May 3, 2024 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Apr 26, 2024 (Past Non-Compliance)

▲ Immediate jeopardy, one-off · Dec 21, 2023 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Feb 5, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (125)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 19, 2026▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 6, 2026▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 22, 2026▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 14, 2026▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 14, 2026▲ G · Actual harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Apr 14, 2026D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Mar 20, 2026▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 12, 2026▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 12, 2026▲ G · Actual harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Mar 12, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 26, 2026▲ H · Actual harm, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 26, 2026▲ G · Actual harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Feb 26, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 26, 2026E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jan 8, 2026▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jan 8, 2026D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Dec 22, 2025▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 25, 2025▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 25, 2025E · Potential for harm, repeatedThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint
Nov 20, 2025D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Aug 29, 2025E · Potential for harm, repeatedThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Aug 22, 2025▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Aug 22, 2025E · Potential for harm, repeatedThe facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint
Aug 22, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Aug 22, 2025D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint
Aug 22, 2025D · Potential for harm, one-offThe facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint
Jul 31, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jul 31, 2025E · Potential for harm, repeatedThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Jul 31, 2025E · Potential for harm, repeatedThe facility did not provide a bathroom in or near each resident's room. · from a complaint
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 28, 2025E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint
Apr 28, 2025E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 28, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 28, 2025D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 5, 2025▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 5, 2025D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Mar 5, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 31, 2025▲ K · Immediate jeopardy, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jan 31, 2025E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jan 31, 2025D · Potential for harm, one-offThe facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint
Jan 3, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jan 3, 2025D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Dec 19, 2024E · Potential for harm, repeatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Dec 19, 2024E · Potential for harm, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 19, 2024E · Potential for harm, repeatedThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Dec 19, 2024E · Potential for harm, repeatedThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Dec 19, 2024E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Nov 15, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 4, 2024E · Potential for harm, repeatedThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Sep 12, 2024▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Sep 12, 2024D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Sep 12, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 15, 2024E · Potential for harm, repeatedThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
Aug 15, 2024D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Aug 15, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Aug 15, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 31, 2024▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 25, 2024▲ K · Immediate jeopardy, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jun 25, 2024D · Potential for harm, one-offThe facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint
May 30, 2024D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
May 30, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 3, 2024▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 3, 2024E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 9, 2024▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 9, 2024E · Potential for harm, repeatedThe facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint
Feb 9, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 21, 2023▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 21, 2023D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Dec 21, 2023D · Potential for harm, one-offThe facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint
Dec 21, 2023D · Potential for harm, one-offThe facility did not notify the appropriate authorities when a resident with a mental disorder or intellectual disability had a significant change in condition. · from a complaint
Dec 21, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 30, 2023▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 30, 2023D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Nov 16, 2023▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 16, 2023F · Potential for harm, facility-wideThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Nov 16, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Nov 16, 2023D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Oct 18, 2023▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Oct 18, 2023D · Potential for harm, one-offThe facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint
Oct 6, 2023D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Aug 30, 2023E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Aug 2, 2023D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 7, 2023E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
May 7, 2023E · Potential for harm, repeatedThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
May 7, 2023E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 7, 2023E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
May 7, 2023E · Potential for harm, repeatedThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
May 7, 2023E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
May 7, 2023E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
May 7, 2023E · Potential for harm, repeatedThe facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
May 7, 2023E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 7, 2023E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 7, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 7, 2023E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 7, 2023E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 7, 2023E · Potential for harm, repeatedThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
May 7, 2023D · Potential for harm, one-offThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences.
May 7, 2023D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
May 7, 2023D · Potential for harm, one-offThe facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy.
May 7, 2023D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 7, 2023D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 7, 2023C · Minimal risk, facility-wideThe facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time.
May 27, 2021E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
May 27, 2021E · Potential for harm, repeatedThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 27, 2021E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 27, 2021E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
May 27, 2021D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
May 27, 2021D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 27, 2021D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
May 27, 2021D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (20 → 20).

YearCitationsSerious (G–L)Worst severity that year
202180E
2023364J ▲
2024246K ▲
2025415K ▲
20261611J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

13 fines totaling $1,148,689, plus 4 Medicare payment denial periods.

DateTypeAmount / length
Feb 26, 2026Fine$564,745
Feb 26, 2026Payment Denial53 days from Apr 9, 2026
Jan 8, 2026Fine$14,895
Dec 22, 2025Fine$14,819
Nov 20, 2025Fine$25,012
Jul 31, 2025Fine$12,627
Apr 28, 2025Fine$14,768
Apr 28, 2025Payment Denial6 days from Jun 6, 2025
Dec 19, 2024Fine$161,129
Nov 15, 2024Fine$12,038
Aug 15, 2024Fine$51,266
Aug 15, 2024Payment Denial11 days from Oct 16, 2024
Jul 31, 2024Fine$14,050
May 30, 2024Fine$54,406
May 3, 2024Fine$16,801
Nov 16, 2023Fine$192,133
Nov 16, 2023Payment Denial93 days from Dec 27, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMissouri avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.263.663.95bottom 9% in Missouri; bottom 2% in the U.S.
Registered Nurse hours0.140.490.69bottom 4% in Missouri; bottom 1% in the U.S.
Weekend total nurse staffing2.063.223.50bottom 10% in Missouri; bottom 2% in the U.S.
Weekend RN hours (not acuity-adjusted)0.130.330.48bottom 9% in Missouri; bottom 3% in the U.S.
Total nursing staff turnover (%)58.356.045.8bottom 45% in Missouri; bottom 19% in the U.S.
RN turnover (%)50.047.842.9top 46% in Missouri; bottom 39% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.45, RN 0.15, weekend 2.24. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Destefane, RichardIndividualIndirect Ownership InterestNOT APPLICABLE03/01/2018
RC Tier Properties, L.L.C.OrganizationDirect Ownership InterestNOT APPLICABLE09/28/2018
Reliant Care Group LLCOrganizationIndirect Ownership InterestNOT APPLICABLE01/11/2008
Richard J. Destefane Revocable Living TrustOrganizationIndirect Ownership InterestNOT APPLICABLE03/01/2018
Arshad, AbdullahIndividualOperational/Managerial ControlNOT APPLICABLE09/15/2024
Arshad, AbdullahIndividualADP of the SNFNOT APPLICABLE09/15/2024
Destefane, RichardIndividualOperational/Managerial ControlNOT APPLICABLE01/11/2008
Moore, RhondaIndividualOperational/Managerial ControlNOT APPLICABLE02/26/2025
Moore, RhondaIndividualADP of the SNFNOT APPLICABLE02/26/2025
Reliant Care Management Company LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/11/2008
Reliant Care Management Company LLCOrganizationADP of the SNFNOT APPLICABLE04/16/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 265822.