Cycle 1
Health 2025-02-13 · Fire 2025-02-13
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Springfield, MO
Birch Pointe Health And Rehabilitation
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3705 S Jefferson Ave, Springfield, MO
(417) 889-0773
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Anthony & Bryan Adams
Operator or chain grouping
Approved since
2017-12-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 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
0.49
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,352
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9899
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.25
Baseline 18.17% · Performance 19.93% · Measure score 3.25 · Achievement 3.25 · Improvement 0
Healthcare-associated infections
5.03
Baseline 5.58% · Performance 6.33% · Measure score 5.03 · Achievement 5.03 · Improvement 0
Total nurse turnover
3.84
Baseline 64.13% · Performance 48.00% · Measure score 3.84 · Achievement 3.84 · Improvement 3.61
Adjusted total nurse staffing
2.49
Baseline 3.50 hours · Performance 3.79 hours · Measure score 2.49 · Achievement 2.49 · Improvement 0.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 8.46% · Lower 95% interval 7.32% |
| Discharge to community | 48.81% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 40.71% · Lower 95% interval 40.84% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 59.65% |
53.69%
6 pts better
|
Numerator 34 · Denominator 57 |
| Discharge mobility score | 56.14% |
50.94%
5.2 pts better
|
Numerator 32 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 8.43% |
2.29%
6.1 pts worse
|
Numerator 7 · Denominator 83 · Adjusted rate 9.74% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 1.77% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 113 |
| Staff flu vaccination coverage | 24.86% |
42%
17.1 pts worse
|
Numerator 43 · Denominator 173 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 39 · Denominator 57 |
| Transfer of health information to provider | 86.36% |
95.95%
9.6 pts worse
|
Numerator 19 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 6.12% |
25.2%
19.1 pts worse
|
Numerator 3 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.3
0.4 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
84.8%
14.9 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7% |
| 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 | 11.5% |
4.1%
7.4 pts worse
|
3.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 10.5% · Q3 10.7% · Q4 11.6% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 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 who lose too much weight | 3.8% |
5.5%
1.7 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.6% · Q3 1.5% · Q4 2.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
25.3%
4.1 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 20.8% · Q3 19.7% · Q4 24.7% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
25.0%
7.3 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 16.2% · Q3 18.6% · Q4 15.3% · 4Q avg 17.7% · 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 | 10.4% |
20.3%
9.9 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 8.9% · Q3 9.0% · Q4 7.3% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
19.8%
10.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 19.4% · Q3 6.0% · Q4 7.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.4%
1.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 12.2% |
18.1%
5.9 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 15.5% · Q3 7.2% · Q4 14.3% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.0%
0.1 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.2% · Q3 4.9% · Q4 3.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
66.4%
33.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
13.4%
3.3 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.2%
1.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 30.7% |
63.5%
32.8 pts worse
|
79.7%
49 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 30.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
25.3%
6.3 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.8% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-06-02 · Fire 2021-06-02
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
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 2025-03-30
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-30
E · Potential for more than minimal harm
2023-12-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-15
F · Potential for more than minimal harm
2021-06-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-07-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
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 2025-03-30
E · Potential for more than minimal harm
2025-02-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-02-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-02-13
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 2025-03-30
E · Potential for more than minimal harm
2025-02-13
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 2025-03-30
E · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-30
G · Actual 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 2024-10-02
E · Potential for more than minimal harm
2024-07-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-26
F · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-01
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 2024-01-15
E · Potential for more than minimal harm
2023-12-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-01
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 2024-01-15
D · Potential for more than minimal harm
2023-12-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-08-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-01
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 2023-09-14
D · Potential for more than minimal harm
2023-08-01
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-09-14
F · Potential for more than minimal harm
2021-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-17
E · Potential for more than minimal harm
2021-06-02
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 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-07-17
D · Potential for more than minimal harm
2021-06-02
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-07-17
Penalties and ownership
What sits behind the stars
Ownership
Rhc Operations Inc
5% Or Greater Direct Ownership Interest · Organization
Adams, Anthony
5% Or Greater Indirect Ownership Interest · Individual
Adams, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Adams, Anthony
Corporate Officer · Individual
Adams, Bryan
Corporate Officer · Individual
Alumno, Martin
Operational/Managerial Control · Individual
Dvorak, Nora
Corporate Director · Individual
Lowe, Clinton
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Cox Medical Centers Meyer Orthopedic And Rehab
Springfield, MO
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Springfield Villa
Springfield, MO
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Maples Health And Rehabilitation, The
Springfield, MO
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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