Cycle 1
Health 2024-02-06 · Fire 2024-02-06
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Kansas City, MO
Bishop Spencer Place, Inc, The
3-star overall rating with 3-star inspections with $8,021 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
4301 Madison Avenue, Kansas City, MO
(816) 931-4277
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.85
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.72
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.19
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
2.57
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
5.67
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,646
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0023
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.45
Baseline 19.66% · Performance 19.83% · Measure score 3.45 · Achievement 3.45 · Improvement 0
Healthcare-associated infections
6.99
Baseline 5.02% · Performance 5.75% · Measure score 6.99 · Achievement 6.99 · Improvement 0
Total nurse turnover
2.84
Baseline 32.26% · Performance 52.05% · Measure score 2.84 · Achievement 2.84 · Improvement 0
Adjusted total nurse staffing
6.13
Baseline 4.65 hours · Performance 4.82 hours · Measure score 6.13 · Achievement 6.13 · Improvement 1.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 11.89% · Lower 95% interval 8.83% |
| Discharge to community | 56.83% |
50.57%
6.3 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 48.68% · Lower 95% interval 49.86% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 141 · Denominator 144 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 144 |
| Discharge self-care score | 48.25% |
53.69%
5.4 pts worse
|
Numerator 55 · Denominator 114 |
| Discharge mobility score | 65.79% |
50.94%
14.9 pts better
|
Numerator 75 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 144 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 4.23% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 154 |
| Staff flu vaccination coverage | 86.11% |
42%
44.1 pts better
|
Numerator 124 · Denominator 144 |
| Discharge function score | 62.28% |
56.45%
5.8 pts better
|
Numerator 71 · Denominator 114 |
| Transfer of health information to provider | 75% |
95.95%
21 pts worse
|
Numerator 21 · Denominator 28 |
| Transfer of health information to patient | 80.2% |
96.28%
16.1 pts worse
|
Numerator 81 · Denominator 101 |
| Resident COVID-19 vaccinations up to date | 17.19% |
25.2%
8 pts worse
|
Numerator 11 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.1
1.4 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.4 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
84.8%
10.9 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 95.7% · Q4 90.0% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.2% |
90.9%
5.7 pts worse
|
95.5%
10.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.1%
4.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 6.7% |
14.7%
8 pts better
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 13.0% · Q4 10.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.5%
3.2 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
25.3%
10.4 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 19.0% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
25.0%
10.7 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · 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 need for help with daily activities has increased | 11.6% |
19.8%
8.2 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 20.0% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.4%
0.3 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.0% |
2.6%
4.4 pts worse
|
1.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 13.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
18.1%
5.2 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 8.5% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 11.2% |
5.0%
6.2 pts worse
|
5.1%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 10.1% · Q3 14.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
66.4%
13.1 pts better
|
81.7%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 75.1% · Q3 73.1% · Q4 82.6% · 4Q avg 79.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
13.4%
5.4 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.8% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
2.2%
0.1 pts better
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.5% · Q3 2.6% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.6% |
63.5%
4.1 pts better
|
79.7%
12.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
25.3%
2.5 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 24.6% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-19 · Fire 2022-07-19
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-19 · Fire 2019-09-19
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
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.
Not marked corrected
F · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
F · Potential for more than minimal harm
2024-02-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-06
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-03-22
F · Potential for more than minimal harm
2019-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-02
F · Potential for more than minimal harm
2019-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-02
F · Potential for more than minimal harm
2019-09-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-11-02
E · Potential for more than minimal harm
2019-09-19
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2019-11-02
E · Potential for more than minimal harm
2019-09-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-11-02
Inspection history
Recent health citations
J · Immediate jeopardy
2024-07-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-02-06
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 2024-03-22
E · Potential for more than minimal harm
2024-02-06
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-06
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 2024-03-22
E · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-22
D · Potential for more than minimal harm
2023-08-29
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-06-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-03
E · Potential for more than minimal harm
2022-07-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-07-19
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-07-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-02
E · Potential for more than minimal harm
2019-09-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-11-02
E · Potential for more than minimal harm
2019-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-02
D · Potential for more than minimal harm
2019-09-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-11-02
D · Potential for more than minimal harm
2019-09-19
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 2019-11-02
D · Potential for more than minimal harm
2019-09-19
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-11-02
Penalties and ownership
What sits behind the stars
$8,021
2024-07-29
Fine
Fine · fine $8,021
Fine
Ownership
Achelphol, Richard
Operational/Managerial Control · Individual
Achelphol, Richard
Corporate Director · Individual
Calvin, Karen
Operational/Managerial Control · Individual
Calvin, Karen
Corporate Director · Individual
Coulter, James
Operational/Managerial Control · Individual
Coulter, James
Corporate Director · Individual
Elving, Beverly
Operational/Managerial Control · Individual
Elving, Beverly
Corporate Director · Individual
Havenhill, Lisa
Operational/Managerial Control · Individual
Havenhill, Lisa
Corporate Director · Individual
Havenhill, Lisa
Corporate Officer · Individual
Hutcherson, Anne
Operational/Managerial Control · Individual
Hutcherson, Anne
Corporate Director · Individual
Jackson, Anthony
Operational/Managerial Control · Individual
Johnson, Jani
Operational/Managerial Control · Individual
Johnson, Jani
Corporate Director · Individual
Johnston, Nanette
Operational/Managerial Control · Individual
Johnston, Nanette
Corporate Director · Individual
Keyse, Andrew
Operational/Managerial Control · Individual
Keyse, Andrew
Corporate Director · Individual
Lampo, Jane
Operational/Managerial Control · Individual
Lampo, Jane
Corporate Director · Individual
Mcbride, Sydney
Operational/Managerial Control · Individual
Mcbride, Sydney
Corporate Director · Individual
Mcbride, Sydney
Corporate Officer · Individual
Meaux, Amy
Operational/Managerial Control · Individual
Meaux, Amy
Corporate Director · Individual
Purcell, Jason
Operational/Managerial Control · Individual
Purcell, Jason
Corporate Director · Individual
Saint Lukes Health System Inc
Operational/Managerial Control · Organization
Sparks, Randy
Operational/Managerial Control · Individual
Wootton, Kristen
Operational/Managerial Control · Individual
Wootton, Kristen
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Summit, The
Kansas City, MO
2-star overall rating with 1-star inspections with 26 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Clara Manor Nursing Home
Kansas City, MO
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $18,180 in total fines with 37 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Ignite Medical Resort Rainbow Boulevard, LLC
Kansas City, KS
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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