Hilltop at Blue River, the
10425 Chestnut Dr, Kansas City, MO 64137 · Jackson County · 160 certified beds · avg 147 residents/day · certified since Nov 23, 1994
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$0
Fines, last 3 years
2.31
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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)
▲ Actual harm, one-off · Jul 21, 2023 · F-0689
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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 24, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 21, 2023 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 24, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (48)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 1, 2026 | D · Potential for harm, one-off | 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. · from a complaint |
| Jan 2, 2026 | D · Potential for harm, one-off | The 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 |
| Dec 18, 2025 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. · from a complaint |
| Mar 14, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Mar 14, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 14, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 14, 2025 | D · Potential for harm, one-off | The 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 14, 2025 | D · Potential for harm, one-off | The 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. |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Mar 14, 2025 | D · Potential for harm, one-off | The 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. |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Nov 8, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 21, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 21, 2023 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Jul 21, 2023 | E · Potential for harm, repeated | The 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jul 21, 2023 | E · Potential for harm, repeated | The 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not provide a neutral and fair arbitration process. Arbitration is a way of settling disputes outside of court, and if it's used, the facility must agree with the resident on a neutral arbitrator and a convenient location. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jul 21, 2023 | E · Potential for harm, repeated | The 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The 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. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Jul 21, 2023 | D · Potential for harm, one-off | The 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. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 16, 2021 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 16, 2021 | E · Potential for harm, repeated | The 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. |
| Mar 16, 2021 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (28 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 3 | 0 | E |
| 2023 | 29 | 2 | G ▲ |
| 2024 | 1 | 0 | D |
| 2025 | 13 | 0 | E |
| 2026 | 2 | 0 | D |
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)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Missouri avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.31 | 3.66 | 3.95 | bottom 11% in Missouri; bottom 2% in the U.S. |
| Registered Nurse hours | 0.22 | 0.49 | 0.69 | bottom 13% in Missouri; bottom 4% in the U.S. |
| Weekend total nurse staffing | 2.06 | 3.22 | 3.50 | bottom 11% in Missouri; bottom 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.33 | 0.48 | bottom 39% in Missouri; bottom 18% in the U.S. |
| Total nursing staff turnover (%) | 37.9 | 56.0 | 45.8 | top 9% in Missouri; top 31% in the U.S. |
| RN turnover (%) | 20.0 | 47.8 | 42.9 | top 12% in Missouri; top 13% 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 2.62, RN 0.25, weekend 2.33. 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: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Caliber Advisors LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/22/2022 |
| Crestview Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| El Dorado Nursing and Rehabilitation LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| First Sweetzer Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| Hatteras Investments LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| Rimpau Holdings Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| Sasem Investments LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/12/2022 |
| 10425 Chestnut Drive Mo, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/12/2022 |
| 10425 Chestnut Drive Mo, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Emerald Property Partners LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/12/2022 |
| Emerald Property Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Esdov Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| First Sweetzer Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/12/2022 |
| Gibraltar Trust | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/12/2022 |
| Gibraltar Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 05/16/2025 |
| Hatteras Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Jubilee Master Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Kaplan, Esther | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/14/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How do you involve a resident's representative in care decisions, and how quickly are they consulted?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Bridgewood Health Care Center | 1.7 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Kingswood Senior Living | 2.1 mi | Kansas City, MO | ★★★☆☆ | 3/5 | |
| Ignite Medical Resort Carondelet LLC | 2.3 mi | Kansas City, MO | ★☆☆☆☆ | 2/5 | |
| Hope Care Center | 3.3 mi | Kansas City, MO | ★★★★★ | 4/5 | |
| Life Care Center of Grandview | 3.3 mi | Grandview, MO | ★★☆☆☆ | 2/5 | abuse |
| Rehab of Kansas City South | 3.4 mi | Kansas City, MO | ★☆☆☆☆ | 2/5 | abuse |
| Armour Oaks Senior Living Community | 3.7 mi | Kansas City, MO | ★★☆☆☆ | 3/5 | |
| Jeanne Jugan Center | 4.1 mi | Kansas City, MO | ★★★★★ | 5/5 | |
| Advanced Health Care of Overland Park | 4.4 mi | Overland Park, KS | ★★★★★ | 3/5 | |
| Gregory Ridge Health Care Center | 4.5 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
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Facility data as of CMS processing date 2026-08-01. CCN 265597.