Cycle 1
Health 2025-01-10 · Fire 2025-01-10
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Mountain Grove, MO
Autumn Oaks Caring Center
1-star overall rating with 2-star inspections with $63,057 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1310 Hovis Street, Mountain Grove, MO
(417) 926-5128
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Circle B Enterprises
Operator or chain grouping
Approved since
1989-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 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
0.51
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,408
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.39
Baseline 20.44% · Performance 20.32% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Healthcare-associated infections
0
Baseline 8.51% · Performance 9.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.09
Baseline 66.67% · Performance 64.21% · Measure score 0.09 · Achievement 0 · Improvement 0.09
Adjusted total nurse staffing
4.26
Baseline 3.43 hours · Performance 4.29 hours · Measure score 4.26 · Achievement 4.26 · Improvement 3.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 63 · Observed rate 11.11% · Lower 95% interval 6.8% |
| Discharge to community | 40.45% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 34.15% · Lower 95% interval 31.83% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 48% |
53.69%
5.7 pts worse
|
Numerator 12 · Denominator 25 |
| Discharge mobility score | 28% |
50.94%
22.9 pts worse
|
Numerator 7 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 11.11% |
2.29%
8.8 pts worse
|
Numerator 4 · Denominator 36 · Adjusted rate 10.15% |
| Healthcare-associated infections requiring hospitalization | 9.21% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 5.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 17.65% |
42%
24.4 pts worse
|
Numerator 18 · Denominator 102 |
| Discharge function score | 52% |
56.45%
4.5 pts worse
|
Numerator 13 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 65.1% |
84.8%
19.7 pts worse
|
93.4%
28.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 64.6% · Q3 60.3% · Q4 59.4% · 4Q avg 65.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.4% |
90.9%
0.5 pts worse
|
95.5%
5.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
4.1%
3.3 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.7% |
14.7%
5 pts worse
|
11.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 13.0% · Q3 21.8% · Q4 37.5% · 4Q avg 19.7% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.5%
0.8 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.2% · Q3 2.2% · Q4 5.2% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
25.3%
3.3 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 27.5% · Q3 27.1% · Q4 29.3% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.0% |
25.0%
10 pts worse
|
16.7%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 36.4% · Q3 39.4% · Q4 24.2% · 4Q avg 35.0% · 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 | 42.2% |
20.3%
21.9 pts worse
|
16.3%
25.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 48.5% · Q4 27.7% · 4Q avg 42.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
19.8%
7.5 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 34.7% · Q3 19.1% · Q4 19.3% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
1.4%
2.8 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.2% · Q3 3.7% · Q4 4.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
18.1%
7.9 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 38.2% · Q3 16.7% · Q4 19.0% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
5.0%
5.6 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 10.4% · Q3 12.3% · Q4 16.3% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 42.9% |
66.4%
23.5 pts worse
|
81.7%
38.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 41.5% · Q3 37.9% · Q4 47.1% · 4Q avg 42.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.2%
1.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 3.6% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 36.2% |
63.5%
27.3 pts worse
|
79.7%
43.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-11-08 · Fire 2019-11-08
5 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-02-23
F · Potential for more than minimal harm
2023-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-07-17
F · Potential for more than minimal harm
2019-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-11-08
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-11-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2019-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-04-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-16
J · Immediate jeopardy
2025-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-23
G · Actual harm
2025-01-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-23
E · Potential for more than minimal harm
2023-10-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-30
J · Immediate jeopardy
2023-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-25
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
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 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F761 · Pharmacy Service Deficiencies
Health
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.
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
E · Potential for more than minimal harm
2023-06-02
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-06-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-17
C · Minimal harm
2023-06-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-03-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-29
E · Potential for more than minimal harm
2019-11-08
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 2019-12-23
D · Potential for more than minimal harm
2019-11-08
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 2019-12-23
D · Potential for more than minimal harm
2019-11-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-12-23
Penalties and ownership
What sits behind the stars
$48,539
2025-01-10
Fine
Fine · fine $48,539
Fine
$0
2025-01-10
Payment Denial
Payment Denial · denial start 2025-02-15 · 8 days
8 day denial
$14,518
2023-06-02
Fine
Fine · fine $14,518
Fine
Ownership
Circle B Enterprises Holding Company Inc
5% Or Greater Direct Ownership Interest · Organization
Agh1 LLC
Operational/Managerial Control · Organization
Beaird, Todd
Corporate Officer · Individual
Bedell, Donald
Operational/Managerial Control · Individual
Bedell, Donald
Corporate Director · Individual
Bedell, Donald
Corporate Officer · Individual
Beers, Jonathan
Operational/Managerial Control · Individual
Britton, Kevin
Corporate Officer · Individual
Miller, Cassie
Operational/Managerial Control · Individual
Sovereign Healthcare Group LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Kabul Nursing Homes Inc
Cabool, MO
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Rocky Ridge Manor
Mansfield, MO
3-star overall rating with 3-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hartville Care Center
Hartville, MO
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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