Cycle 1
Health 2023-12-08 · Fire 2023-12-08
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bolivar, MO
Citizens Memorial Healthcare Facility
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1218 West Locust, Bolivar, MO
(417) 326-7648
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Citizens Memorial Health Care
Operator or chain grouping
Approved since
1993-09-27
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
0.55
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.93
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.84
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
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.50
Performance 18.88% · Measure score 5.50 · Achievement 5.50 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.14
Performance 6.30% · Measure score 5.14 · Achievement 5.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.08
Baseline 74.16% · Performance 56.52% · Measure score 3.08 · Achievement 1.75 · Improvement 3.08
Adjusted total nurse staffing
0
Baseline 3.88 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 6.47% |
| Discharge to community | 49.54% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 41.18% · Lower 95% interval 37.24% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 89.29% |
95.27%
6 pts worse
|
Numerator 25 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 5 · Denominator 20 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 4 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 4.72% |
8.2%
3.5 pts worse
|
Numerator 6 · Denominator 127 |
| Staff flu vaccination coverage | 84.03% |
42%
42 pts better
|
Numerator 100 · Denominator 119 |
| Discharge function score | 30% |
56.45%
26.5 pts worse
|
Numerator 6 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · 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 13 · 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 | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.3
0.9 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
84.8%
12.5 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.7% · Q3 97.5% · Q4 97.5% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
90.9%
8.1 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
4.1%
2.9 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.3% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
14.7%
13.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.5%
4.2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.4% · Q4 2.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
25.3%
0.1 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 27.5% · Q3 29.2% · Q4 23.0% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
25.0%
8.9 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.5% · Q3 17.9% · Q4 17.5% · 4Q avg 16.1% · 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 | 26.7% |
20.3%
6.4 pts worse
|
16.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 14.3% · Q3 26.9% · Q4 34.8% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
19.8%
2.3 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 23.0% · Q3 22.1% · Q4 23.9% · 4Q avg 22.1% · 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 | 6.6% |
2.6%
4 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.7% · Q3 6.6% · Q4 10.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
18.1%
5.8 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 9.4% · Q3 12.7% · Q4 10.3% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.0%
1.6 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.7% · Q3 1.3% · Q4 3.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
66.4%
30.4 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 94.6% · Q3 100.0% · Q4 98.6% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
13.4%
2.2 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.2%
0.3 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.0% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
63.5%
27.7 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
25.3%
0.4 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 29.4% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-16 · Fire 2021-04-16
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-02-26 · Fire 2019-02-26
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-21
E · Potential for more than minimal harm
2021-04-16
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 2021-04-25
E · Potential for more than minimal harm
2021-04-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-07
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 2025-08-16
D · Potential for more than minimal harm
2024-10-24
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 2024-12-08
E · Potential for more than minimal harm
2023-12-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-08
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 2024-01-21
D · Potential for more than minimal harm
2023-12-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-09-26
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 2023-11-10
D · Potential for more than minimal harm
2023-09-26
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 2023-11-10
E · Potential for more than minimal harm
2023-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-16
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-31
E · Potential for more than minimal harm
2021-04-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-05-04
E · Potential for more than minimal harm
2021-04-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-05-31
E · Potential for more than minimal harm
2021-04-16
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 2021-05-31
D · Potential for more than minimal harm
2021-04-16
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 2021-05-31
E · Potential for more than minimal harm
2019-02-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-03-30
E · Potential for more than minimal harm
2019-02-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-03-30
E · Potential for more than minimal harm
2019-02-26
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 2019-05-20
E · Potential for more than minimal harm
2019-02-26
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 2019-03-30
D · Potential for more than minimal harm
2019-02-26
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 2019-03-30
D · Potential for more than minimal harm
2019-02-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-30
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
Francka, Tim
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
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
Parkview Health Care Facility
Bolivar, MO
5-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Big Spring Care Center For Rehab And Healthcare
Humansville, MO
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Northwood Hills Care Center
Humansville, MO
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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