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Nursing HomeMedicaid Investigative

Carmel Hills Wellness & Rehabilitation

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

810 East Walnut, Independence, MO 64050194 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 270 Google reviews

5
4
3
2
1
Carmel Hills Wellness & Rehabilitation Nursing Home in Independence, MO — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (30 vs median 10)
  • High staff turnover (56%)

Bottom 25% in MO · Critically understaffed (RN) · Worst in EL DORADO NURSING AND REHABILITATION chain · $20,787 in fines

Source: Medicare data

What this means for your family

While recent renovations and community engagement efforts have improved the facility's atmosphere, the reports of severe hygiene issues and medical neglect are critical red flags. If you choose to tour, pay close attention to the smell in the hallways and ask specific questions about the nurse-to-patient ratio and how they handle medication management for complex cases.

Google Reviews

Google Reviews

270 reviews on Google
Carmel Hills Wellness & Rehabilitation receives highly polarized feedback, with many families praising the recent management changes, facility renovations, and compassionate nursing staff. However, a significant number of reviewers report severe concerns regarding hygiene, including persistent odors, and critical lapses in medical care, communication, and responsiveness.

Quality Themes

Tap a score for details
Food4.0Staff5.0Clean3.0Activities8.0Meds2.0Memory6.0Comms3.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Recent facility renovations and clean common areas
  • Effective rehabilitation therapy team
  • Welcoming and helpful administrative staff

Concerns

  • Persistent, overwhelming odor of urine and feces (mentioned by 5 reviewers)
  • Inadequate communication and failure to answer phones (mentioned by 4 reviewers)
  • Neglect of basic medical needs and medication management (mentioned by 6 reviewers)
  • High staff-to-patient ratios leading to slow response times (mentioned by 3 reviewers)
  • Missing or stolen personal belongings (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

2344.42021(12)3.92022(34)4.32023(31)3.82024(34)4.52025(78)3.82026(19)

Distribution · 208 analyzed

5
142
4
25
3
8
2
2
1
31
21 reviews posted between Jul 14, 2025Jul 14, 2025 · 21 were 5-star

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the recent facility renovations, what specific protocols are currently in place to ensure that common areas and resident rooms maintain a consistently fresh and sanitary environment?
  • 2Could you walk me through the current process for medication management and how the nursing team ensures that prescriptions are administered accurately and on time?
  • 3What is your facility's policy regarding communication with families, and what is the best way to ensure we receive timely updates regarding our loved one's health and daily status?
  • 4With your current staffing levels, what is the typical response time for call lights, and how do you prioritize assistance during peak hours?
  • 5What measures are in place to secure personal belongings and ensure that residents' items are tracked and protected within their living spaces?
  • 6How does your rehabilitation team integrate with the nursing staff to ensure that a resident’s medical needs are met while they are actively participating in therapy sessions?

Personalized based on this facility's data


Key Review Excerpts

My husband and I came to visit a Friend. First time ever to come to this facility. My Friend needed to be hoisted from a chair to her bed. Three persons came and immediately took care of her. She needed a smaller wheelchair. A therapist got that for her.

Visitor · 2024★★★★

My dad was placed in nursing care here at Carmel Hills. The staff was always kind and respectful of him and of us. Carrie and Sara in the business office were so helpful.

Long-term resident's family · 2024★★★★

My mother was here 3 hrs and unexpectedly died in their care. Left st Joseph hospital laughing smiling talking n eating that morning to just die in 3 hrs of being there. Her money she transferred with Missing Stolen. Her belongings was rummaged through on the floor.

Memory care family member · 2025☆☆☆☆
Source: 270 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.30hrs
40%
Registered nurses for medical care
Total Nursing
2.80hrs
68%
All nurses + aides combined
Staff Turnover
59%
Lower is better (< 30% = good)
RN Turnover
40%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

6

measures

Mixed Results

3

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility75.0%
Worse than Avg
Here
75.0%
US
12.1%
MO
16.7%
Jackson
9.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility75.4%
Worse than Avg
Here
75.4%
US
93.4%
MO
84.4%
Jackson
95.7%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility10.7%
Better than Avg
Here
10.7%
US
15.4%
MO
23.6%
Jackson
16.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.6%
Better than Avg
Here
7.6%
US
15.3%
MO
18.9%
Jackson
17.4%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility30.2%
Worse than Avg
Here
30.2%
US
19.5%
MO
25.4%
Jackson
21.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility9.6%
Better than Avg
Here
9.6%
US
14.4%
MO
19.1%
Jackson
15.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility26.9%
Worse than Avg
Here
26.9%
US
81.8%
MO
65.9%
Jackson
88.2%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility35.6%
Worse than Avg
Here
35.6%
US
79.7%
MO
63.5%
Jackson
86.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.8%
Worse than Avg
Here
2.8%
US
1.6%
MO
2.2%
Jackson
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

31deficiencies
1penalties
Well above state avg (12.0)
19 complaint-triggered
$20,787 in fines

This facility has significant ongoing concerns with families filing multiple complaints that triggered 25 deficiency citations across recent surveys. The most persistent problems involve food service quality and safety, accident prevention and supervision, and medication management errors. While all deficiencies show correction dates, the recurring nature of food service issues, safety hazards, and medication problems across multiple years suggests systemic challenges that families should carefully evaluate during visits.

Mar 31, 2026Complaint
1
0689Potential for harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

May 21, 2025Complaint
7
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0580Potential for harm · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0809Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Jan 16, 2025Complaint
2
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0804Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nov 25, 2024Routine
23
0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0693Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Nov 25, 2024Complaint
2
0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0660Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Oct 16, 2024Complaint
1
0602Potential for harm · PatternResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Federal Penalties

Fine

Feb 1, 2024

$20,787

Ownership & Operations

Who Operates This Facility

Owner / Operator

Carmel Hills Wellness & Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Opco Skilled Management

Chain Size

64 facilities nationwide

Chain avg rating: 1.5/5 · Rank 6 of 6 (Worst)

Ownership & Management

Owners

El Dorado Nursing and Rehabilitation LLC

Owner · Organization

Caliber Advisors LLC

Owner (parent company) · Organization

Crestview Trust

Owner (parent company) · Organization

First Sweetzer Holdings LLC

Owner (parent company) · Organization

Hatteras Investments LLC

Owner (parent company) · Organization

Rimpau Holdings Trust

Owner (parent company) · Organization

Sasem Investments LLC

Owner (parent company) · Organization

Hagins, Elizabeth

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Kaplan, Esther

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Kaplan, Mordechai

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Kaplan, Mosha

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Sternshein, Jennifer

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Unger, Jeffrey

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Zimmerman, Caroline

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

810 E Walnut Street Mo LLC5% or Greater Mortgage InterestEmerald Property Partners LLC5% or Greater Mortgage InterestGibraltar Trust5% or Greater Mortgage InterestMontgomery Sky Trust5% or Greater Mortgage InterestOzark Healthcare Realty LLC5% or Greater Mortgage Interest
Source: Medicare provider data

Contact

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References & Resources

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Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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