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Nursing HomeMedicaid Investigative

Riverbend Heights Health & Rehabilitation

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

1221 Highway 13 South, Lexington, MO 64067154 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 55 Google reviews

5
4
3
2
1
Riverbend Heights Health & Rehabilitation Nursing Home in Lexington, MO — Street View
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2/ 10
low Risk

Quality Concerns Identified

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

  • Low overall rating (2/5 stars)

Below average in MO · Below recommended RN staffing · Above average staffing · No penalties on record

Source: Medicare data

What this means for your family

While some families report a warm, clean environment and effective rehab, there are recurring, serious allegations regarding medication management and hygiene. We strongly advise you to conduct unannounced visits, specifically checking on medication administration protocols and the responsiveness of staff during off-hours.

Google Reviews

Google Reviews

55 reviews on Google
Riverbend Heights Health & Rehabilitation receives highly polarized feedback, with some families praising the warm, attentive staff and clean environment, while others report severe neglect and communication failures. Critical concerns include medication mismanagement, poor hygiene, and a lack of responsiveness from management during medical emergencies or end-of-life transitions. Prospective families should be aware of the significant disparity between positive testimonials and reports of serious clinical oversight.

Quality Themes

Tap a score for details
Food8.0Staff5.0Clean6.0ActivitiesN/AMeds1.0Memory5.0Comms3.0ValueN/A

Strengths

  • Warm, friendly nursing staff
  • Clean and well-maintained facility
  • Effective rehabilitation therapy
  • Proactive communication systems

Concerns

  • Neglect and poor hygiene (mentioned by 3 reviewers)
  • Medication mismanagement (mentioned by 2 reviewers)
  • Poor communication regarding patient status/death (mentioned by 2 reviewers)
  • Incompetent emergency response (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02017(1)4.22021(11)3.62022(7)3.82023(10)3.42024(5)4.02025(9)2.32026(4)

Distribution · 47 analyzed

5
29
4
4
3
0
2
1
1
13

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the facility's focus on rehabilitation, what specific protocols are in place to ensure consistent medication management and administration for residents?
  • 2I noticed the facility has a proactive communication system; could you walk me through how you keep families updated on changes in a resident's health status or care plan?
  • 3With 154 residents, how does the staff ensure that individual hygiene needs and daily grooming assistance are consistently met for every resident?
  • 4Could you explain the training and response procedures your team follows when a resident experiences a sudden medical emergency?
  • 5I see that you engage with feedback online; how do you use input from families to improve the quality of care and address concerns as they arise?
  • 6What does a typical social calendar look like for residents, and how do you encourage participation to ensure everyone feels included in daily life?

Personalized based on this facility's data


Key Review Excerpts

This facility was warm, clean, and well maintained. But the best review came from the patient I visited. For years he had pled with all “never put me in a nursing home!” But after a brief chat, with his wife by his side, he said, “I like this place! I go to the Cafe for coffee in the morning, and my friends bring me up to date on whats going on!”

Visitor · 2024★★★★★

They had my brother in law there. Very incompetent place. We told them that he would spit out his medications and they would have to watch him. He got so sick and manic that the head of nursing called us and asked if he takes any medication for his mania. We drove out there immediately and he was sitting in his urine and talking so loud you could hear him at the entrance of the place.

Family member · 2024☆☆☆☆

The staff are extremely helpful and friendly and truly want to help their residents have the best life possible. They communicate care of loved ones frequently. They have an automatic messaging system and can send me messages about care, testing, appointments or general info straight to my cell by calls and texts.

Family member · 2023★★★★★
Source: 55 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
70%
Registered nurses for medical care
Total Nursing
3.86hrs
94%
All nurses + aides combined
Staff Turnover
44%
Lower is better (< 30% = good)
RN Turnover
62%
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

5

measures

Mixed Results

4

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility3.6%
Better than Avg
Here
3.6%
US
14.4%
MO
19.1%
Lafayette
18.3%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility35.0%
Worse than Avg
Here
35.0%
US
19.5%
MO
25.4%
Lafayette
23.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility6.3%
Better than Avg
Here
6.3%
US
15.3%
MO
18.9%
Lafayette
19.2%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility84.2%
Worse than Avg
Here
84.2%
US
93.4%
MO
84.4%
Lafayette
89.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility10.7%
Better than Avg
Here
10.7%
US
19.4%
MO
17.9%
Lafayette
17.0%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility23.2%
Mixed vs Avgs
Here
23.2%
US
15.5%
MO
23.6%
Lafayette
19.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility18.2%
Worse than Avg
Here
18.2%
US
79.8%
MO
63.5%
Lafayette
76.1%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility26.9%
Worse than Avg
Here
26.9%
US
81.8%
MO
65.9%
Lafayette
74.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility3.4%
Worse than Avg
Here
3.4%
US
1.6%
MO
2.2%
Lafayette
2.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
Near state avg (12.0)
7 complaint-triggered

This facility has significant concerns, with families filing 7 complaint reports that triggered inspections, including serious issues with resident protection from abuse and neglect. The facility shows recurring problems across fire safety systems, emergency preparedness, medication management, and resident care quality that have persisted across multiple years and surveys. While most deficiencies show correction dates, the pattern of repeated violations in critical areas like safety systems and the recent abuse-related complaints warrant careful consideration before visiting.

Jan 12, 2026Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jun 14, 2024Routine
26
0353Potential for harm · Widespread

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

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.

0908Potential for harm · WidespreadCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0007Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address patient/client population and determine types of services needed.

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0020Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

0030Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

0354Potential for harm · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0911Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0271Potential for harm · Pattern

Egress Deficiencies

Have exits that are accessible at all times.

0761Potential for harm · Pattern

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0921Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0925Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0200Potential for harm · PatternCorrected

Egress Deficiencies

Meet other general requirements.

0300Potential for harm · PatternCorrected

Egress Deficiencies

Meet other general requirements that are deficient.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0804Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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

Jan 23, 2024Complaint
1
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.

Nov 2, 2023Complaint
3
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0741Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

0580Potential for harm · IsolatedCorrected

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.

Sep 11, 2023Complaint
2
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0741Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Sep 23, 2022Routine
33
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.

0814Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0009Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

0013Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0022Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for sheltering.

0025Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

0029Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop a communication plan.

0037Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0211Potential for harm · WidespreadCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0343Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

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

0354Potential for harm · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0678Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

0756Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0758Potential for harm · PatternCorrected

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.

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.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0604Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

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.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Riverbend Heights Health & Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Mo Op Holdco, LLC

Chain Size

9 facilities nationwide

Chain avg rating: 2.4/5 · Rank 8 of 9

Ownership & Management

Owners

Mo Holdco LLC

Owner · Organization

Heitwell Holdings INC

Owner (parent company) · Organization

Reddick Wellington Investments INC

Owner (parent company) · Organization

Redwell Holdings INC

Owner (parent company) · Organization

Geller, Seth

Owner (parent company)

Oberlander, Chaim

Owner (parent company)

Key personnel

Riverbend Heights Property Holdings LLC5% or Greater Security InterestMandelbaum, ChaimManaging Control - Governing BodyCantrell, SidneyManagerKramer, ShmuelManagerLichtenstein, EliManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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