Cycle 1
Health 2025-01-24 · Fire 2025-01-24
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Ash Grove, MO
Ash Grove Healthcare Facility
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
401 North Medical Drive, Ash Grove, MO
(417) 751-2575
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Citizens Memorial Health Care
Operator or chain grouping
Approved since
1994-05-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.89
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.94
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.54
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,179
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.65
Baseline 18.51% · Performance 19.74% · Measure score 3.65 · Achievement 3.65 · Improvement 0
Healthcare-associated infections
5.58
Baseline 6.11% · Performance 6.17% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Total nurse turnover
0
Baseline 54.67% · Performance 68.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.80
Baseline 3.62 hours · Performance 3.59 hours · Measure score 1.80 · Achievement 1.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 11.86% · Lower 95% interval 6.54% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 75.76% |
95.27%
19.5 pts worse
|
Numerator 25 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 14 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 4.84% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 3.01% |
| Staff COVID-19 vaccination coverage | 3.39% |
8.2%
4.8 pts worse
|
Numerator 4 · Denominator 118 |
| Staff flu vaccination coverage | 95.76% |
42%
53.8 pts better
|
Numerator 113 · Denominator 118 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 14 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
84.8%
13.8 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.6% · Q3 98.6% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
4.1%
0.2 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 2.9% · Q4 7.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.5% |
14.7%
5.2 pts better
|
11.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 7.9% · Q3 11.9% · Q4 16.9% · 4Q avg 9.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.5%
2.9 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 1.7% · Q3 1.7% · Q4 2.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.3% |
25.3%
9 pts worse
|
19.6%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 32.8% · Q3 35.5% · Q4 38.2% · 4Q avg 34.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
25.0%
2.3 pts better
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 22.8% · Q3 25.9% · Q4 22.4% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.3% |
20.3%
8 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 50.1% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
19.8%
0.3 pts better
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 10.3% · Q3 22.0% · Q4 26.9% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.4%
1.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.6%
1.1 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 7.2% · Q4 1.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.9% |
18.1%
14.2 pts better
|
19.8%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.3% · Q3 1.3% · Q4 7.4% · 4Q avg 3.9% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.0%
3.9 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
66.4%
27.2 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 90.6% · Q3 94.3% · Q4 97.3% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
13.4%
0.6 pts better
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 12.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.2%
0.8 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
63.5%
30 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.3%
4.8 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 33.3% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2020-03-06 · Fire 2020-03-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-10
F · Potential for more than minimal harm
2023-06-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-06-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-06-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-17
F · Potential for more than minimal harm
2020-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-26
E · Potential for more than minimal harm
2020-03-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-31
E · Potential for more than minimal harm
2020-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-10
E · Potential for more than minimal harm
2024-10-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-22
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-03-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-09-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-08-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-02
F · Potential for more than minimal harm
2023-06-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-17
F · Potential for more than minimal harm
2020-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-07
Penalties and ownership
What sits behind the stars
Ownership
Ashworth, James
Corporate Director · Individual
Babb, Donald
Corporate Director · Individual
Calhoun, Michael
Corporate Officer · Individual
Calhoun, Michael
W-2 Managing Employee · Individual
Derrickson, Beverly
Corporate Director · Individual
Derrickson, Beverly
Corporate Officer · Individual
Derrickson, Beverly
W-2 Managing Employee · Individual
Donnell, William
Corporate Director · Individual
Finnell, Heather
W-2 Managing Employee · Individual
Hancock, Janieca
Corporate Director · Individual
Hancock, Janieca
Corporate Officer · Individual
Johnson, Brad
Corporate Director · Individual
Kallenbach, John
Corporate Director · Individual
Kallenbach, John
Corporate Officer · Individual
Mcbratney, Christopher
W-2 Managing Employee · Individual
Meents, Dana
Corporate Director · Individual
Meyer, Renee
Corporate Officer · Individual
Meyer, Renee
W-2 Managing Employee · Individual
Molder, Catherine
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Willard Care Center
Willard, MO
2-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Springfield Skilled Care Center
Springfield, MO
1-star overall rating with 1-star inspections with 26 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#3
Brookhaven Nursing & Rehab
Springfield, MO
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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