Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

RIVERBEND HEIGHTS HEALTH & REHABILITATION

LEXINGTON, MO · 154 certified beds · Last Life Safety survey June 14, 2024

CMS Certification Number 265358 · first certified March 1989

Ownership

Operated by MO OP HOLDCO, LLC · For profit - Limited Liability company

Ownership changed April 12, 2022 (change of ownership)from SRZ OP RIVERBEND LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within MO

39 citations — more than 92% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 17 citations; the earlier surveys in the window averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (August 2025 to March 2026), and past the point by which nine in ten MO facilities have been surveyed. This facility’s last Life Safety survey was June 2024. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

11 of the 39 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 39 Life Safety citations above. The Physical Environment Index

F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0908 Keep all essential equipment working safely.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	39
Median facility in MO	18
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 9, 2020	3
September 23, 2022	19
June 14, 2024	17

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2022-09-23
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	2	2024-06-14
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2022-09-23
E-0015	Address subsistence needs for staff and patients.	2	2024-06-14
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2024-06-14
K-0712	Have simulated fire drills held at unexpected times.	2	2024-06-14
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	2	2024-06-14
K-0300	Meet other general requirements that are deficient.	1	2024-06-14

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 11
Smoke Deficiencies 11
Miscellaneous Deficiencies 7
Egress Deficiencies 5
Other 5

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	11
Smoke Deficiencies	11
Miscellaneous Deficiencies	7
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	4
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 14, 2024 — 17 citations

Citations issued on June 14, 2024
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (July 18, 2024)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (July 18, 2024)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (July 18, 2024)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (July 18, 2024)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (July 18, 2024)
K-0200	Meet other general requirements.	Deficient, Provider has date of correction (July 18, 2024)
K-0271	Have exits that are accessible at all times.	Waiver has been granted (July 18, 2024)
K-0300	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (July 18, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (July 18, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (July 18, 2024)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (July 18, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (July 18, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (July 18, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (July 18, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (July 18, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Waiver has been granted (July 18, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (July 18, 2024)

September 23, 2022 — 19 citations

Citations issued on September 23, 2022
Tag	What the surveyor checks	Status
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (October 14, 2022)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (October 12, 2022)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (October 18, 2022)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (October 14, 2022)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (October 14, 2022)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (October 14, 2022)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 23, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 27, 2022)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 14, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 28, 2022)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (October 20, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 23, 2022)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (October 5, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 19, 2022)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (November 4, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (September 30, 2022)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (September 30, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 6, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 11, 2022)

January 9, 2020 — 3 citations

Citations issued on January 9, 2020
Tag	What the surveyor checks	Status
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 21, 2020)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 21, 2020)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 21, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.