Riverbend Heights Health & Rehabilitation

Name: Riverbend Heights Health & Rehabilitation
Address: 1221 HIGHWAY 13 SOUTH, Lexington, MO, 64067, US
Telephone: 6602594695

1221 Highway 13 South, Lexington, MO 64067 · Lafayette County · 154 certified beds · avg 82 residents/day · certified since Mar 31, 1989

Part of chain: MO OP HOLDCO, LLC (9 facilities, chain avg rating 2.6★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.88

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 most recent standard health inspection was more than 2 years ago — conditions may have changed.

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 · Nov 2, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 20, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (37)

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
Jan 12, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 14, 2024	F · Potential for harm, facility-wide	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.
Jun 14, 2024	F · Potential for harm, facility-wide	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Jun 14, 2024	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 14, 2024	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 14, 2024	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jun 14, 2024	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Jun 14, 2024	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.
Jun 14, 2024	D · Potential for harm, one-off	The 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.
Jun 14, 2024	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jan 23, 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
Nov 2, 2023	▲ G · Actual 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
Nov 2, 2023	E · Potential for harm, repeated	The 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
Nov 2, 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. · from a complaint
Sep 11, 2023	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
Sep 11, 2023	D · Potential for harm, one-off	The 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
Sep 23, 2022	F · Potential for harm, facility-wide	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.
Sep 23, 2022	F · Potential for harm, facility-wide	The facility did not dispose of garbage and refuse properly.
Sep 23, 2022	E · Potential for harm, repeated	The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Sep 23, 2022	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.
Sep 23, 2022	E · Potential for harm, repeated	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.
Sep 23, 2022	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.
Sep 23, 2022	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.
Sep 23, 2022	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Sep 23, 2022	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Sep 23, 2022	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Sep 23, 2022	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Sep 23, 2022	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.
Sep 23, 2022	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Sep 23, 2022	D · Potential for harm, one-off	The 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.
Jan 9, 2020	E · Potential for harm, repeated	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jan 9, 2020	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 9, 2020	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.
Jan 9, 2020	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Jan 9, 2020	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.
Jan 9, 2020	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.
Jan 9, 2020	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (14 → 9).

Year	Citations	Serious (G–L)	Worst severity that year
2020	7	0	E
2022	14	0	F
2023	5	1	G ▲
2024	10	0	F
2026	1	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)	4.88	3.66	3.95	top 10% in Missouri; top 15% in the U.S.
Registered Nurse hours	0.51	0.49	0.69	top 35% in Missouri; bottom 40% in the U.S.
Weekend total nurse staffing	4.22	3.22	3.50	top 13% in Missouri; top 17% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.31	0.33	0.48	top 40% in Missouri; bottom 34% in the U.S.
Total nursing staff turnover (%)	36.7	56.0	45.8	top 7% in Missouri; top 28% in the U.S.
RN turnover (%)	43.8	47.8	42.9	top 43% in Missouri; bottom 46% 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 3.58, RN 0.38, weekend 3.10. Staffing rating: 4/5.

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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Geller, Seth	Individual	Indirect Ownership Interest	NOT APPLICABLE	04/12/2022
Heitwell Holdings INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	03/11/2024
Mo Holdco LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	04/12/2022
Oberlander, Chaim	Individual	Indirect Ownership Interest	NOT APPLICABLE	04/12/2022
Reddick Wellington Investments INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	03/11/2024
Redwell Holdings INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	03/11/2024
Cantrell, Sidney	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2022
Cantrell, Sidney	Individual	ADP of the SNF	NOT APPLICABLE	04/12/2022
Kramer, Shmuel	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2022
Kramer, Shmuel	Individual	ADP of the SNF	NOT APPLICABLE	04/12/2022
Lichtenstein, Eli	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2022
Lichtenstein, Eli	Individual	ADP of the SNF	NOT APPLICABLE	04/12/2022
Lichtenstein, Isaac	Individual	ADP of the SNF	NOT APPLICABLE	04/12/2022
Mandelbaum, Chaim	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/12/2022
Mandelbaum, Chaim	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2022
Mandelbaum, Chaim	Individual	ADP of the SNF	NOT APPLICABLE	04/12/2022
Mo Holdco LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/12/2022
Riverbend Heights Property Holdings LLC	Organization	5% or Greater Security Interest	NOT APPLICABLE	04/12/2022
Riverbend Heights Property Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/12/2022
Thompson, Ashlie	Individual	Operational/Managerial Control	NOT APPLICABLE	04/12/2022

Questions to ask on your visit

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

"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you inspect and maintain essential equipment, and how quickly are repairs made?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
"How is pest control handled here, and when was the last treatment or inspection?"
"Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
"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
Shirkey Nursing and Rehabilitation Center	8.5 mi	Richmond, MO	★★★☆☆	3/5
Meyer Care Center	9.6 mi	Higginsville, MO	★☆☆☆☆	1/5
Odessa Health Care Center	12.3 mi	Odessa, MO	★☆☆☆☆	1/5
Aspire Senior Living Oak Grove	17.7 mi	Oak Grove, MO	★★☆☆☆	4/5
Apple Ridge Care Center	19.7 mi	Waverly, MO	★☆☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Lexington →

Facility data as of CMS processing date 2026-08-01. CCN 265358.

The Care File

Visit checklist — Riverbend Heights Health & Rehabilitation

1221 Highway 13 South, Lexington, MO 64067 · 6602594695

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Most serious findings on record:

▲ Nov 2, 2023 (F-0600, Actual 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.

Questions for the administrator:

☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
☐ "How is pest control handled here, and when was the last treatment or inspection?"
☐ "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 265358 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)