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
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing
LPN hours / resident day
1.72
Licensed practical nurse staffing
Aide hours / resident day
2.62
Nurse aide staffing
Weekend hours
4.52
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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