Westview Nursing Home: DNR Code Status Confusion - MO
She also said she wasn't sure which color meant which code status.
The inspection, completed May 21, 2025, found that Westview's system for communicating whether a resident should be resuscitated had broken down across multiple layers at once. The dots on the doors, the DNR binder, and the electronic health record were all supposed to say the same thing. Whether they did, and who was responsible for making sure they did, turned out to be questions the facility's own leadership could not answer cleanly.
The Director of Nursing told inspectors that a resident's code status should be consistent throughout the medical record and all facility documentation. That much he knew. What he could not say was where he would expect staff to look to actually find it.
The Administrator offered more detail, but the picture she described raised its own questions. She told inspectors the facility no longer used red dots, explaining that the red dot had been a "stop system" indicating a resident could not be transported during a behavioral emergency. The black dot, she said, meant DNR. She expected staff to know that. She also expected all code status communications to match across the nameplate, the DNR binder, and the electronic health record, and said Medical Records was responsible for keeping the dots and nameplates current.
The nurse who spoke with inspectors had not gotten that message clearly. She was unsure which color was for which code status. In a genuine emergency, her plan was to look at the door, check the chart, and if they conflicted, go find a supervisor. That sequence, in the moments after a resident collapses, is not a protocol. It is improvisation.
The violation was cited at a level of minimal harm or potential for actual harm, meaning inspectors did not document a case where the confusion had already cost a resident their life or caused direct injury. But the gap between "no harm yet" and "no harm possible" is exactly what a functioning code status system is supposed to close. A DNR order exists so that staff do not have to make a judgment call in the worst moment. When the person responsible for carrying it out does not know what the symbol on the door means, the order offers no protection.
Westview is a small facility in a rural county seat about 100 miles northwest of St. Louis. The inspection covered a range of deficiencies across 56 pages. This one appeared on page 20.
The administrator said Medical Records was responsible for updating the dots. The Director of Nursing said he did not know where he would expect staff to look. The nurse said she would check the door, then the chart, then go find someone. Somewhere in that chain, the resident whose code status was in question would be waiting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westview Nursing Home from 2025-05-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
WESTVIEW NURSING HOME in CENTER, MO was cited for violations during a health inspection on May 21, 2025.
She also said she wasn't sure which color meant which code status.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.