Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Columbia, MO
Columbia Post Acute
4-star overall rating with 4-star inspections with 5 recent health deficiencies
3535 Berrywood Drive, Columbia, MO
(573) 397-7144
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2018-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
42%
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
1,740
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.28
Composite VBP score used to determine payment impact.
Payment multiplier
1.0091
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.72
Baseline 16.69% · Performance 17.39% · Measure score 8.72 · Achievement 8.72 · Improvement 0
Healthcare-associated infections
10
Baseline 7.87% · Performance 4.93% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
1.99
Baseline 58.90% · Performance 55.56% · Measure score 1.99 · Achievement 1.99 · Improvement 0.48
Adjusted total nurse staffing
1
Baseline 3.44 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.13% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 797 · Observed rate 8.53% · Lower 95% interval 7.82% |
| Discharge to community | 71.66% |
50.57%
21.1 pts better
|
Better than the National Rate · Eligible stays 852 · Observed rate 66.55% · Lower 95% interval 67.89% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 460 · Denominator 460 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 460 |
| Discharge self-care score | 65.66% |
53.69%
12 pts better
|
Numerator 239 · Denominator 364 |
| Discharge mobility score | 48.08% |
50.94%
2.9 pts worse
|
Numerator 175 · Denominator 364 |
| Pressure ulcers or injuries, new or worsened | 0.22% |
2.29%
2.1 pts better
|
Numerator 1 · Denominator 459 · Adjusted rate 0.38% |
| Healthcare-associated infections requiring hospitalization | 4.93% |
7.12%
2.2 pts better
|
Better than the National Rate · Eligible stays 505 · Observed rate 3.96% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 176 |
| Staff flu vaccination coverage | 33.2% |
42%
8.8 pts worse
|
Numerator 82 · Denominator 247 |
| Discharge function score | 56.87% |
56.45%
0.4 pts better
|
Numerator 207 · Denominator 364 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 94 · Denominator 94 |
| Transfer of health information to patient | 99.72% |
96.28%
3.4 pts better
|
Numerator 357 · Denominator 358 |
| Resident COVID-19 vaccinations up to date | 19.83% |
25.2%
5.4 pts worse
|
Numerator 48 · Denominator 242 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.8%
15.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
4.1%
1.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.3% |
14.7%
12.6 pts worse
|
11.4%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.5%
2.7 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
25.3%
0.3 pts better
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
25.0%
1.9 pts better
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
19.8%
3.1 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · 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 · 4Q avg 0.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.4% |
18.1%
17.3 pts worse
|
19.8%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.4% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.0%
3.2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
66.4%
33.2 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.4% · Q3 99.7% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
13.4%
3.1 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.2%
0.5 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.1% · Q4 0.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
63.5%
30.9 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
25.3%
5.2 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 17.3% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-11 · Fire 2023-08-11
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
2 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-08-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-01
F · Potential for more than minimal harm
2022-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-04-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-04-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-10
Inspection history
Recent health citations
G · Actual harm
2025-02-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-27
E · Potential for more than minimal harm
2024-11-15
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 2024-12-30
E · Potential for more than minimal harm
2024-11-15
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 2024-12-30
D · Potential for more than minimal harm
2024-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-30
C · Minimal harm
2024-11-15
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-12-30
F · Potential for more than minimal harm
2023-08-11
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 2023-09-01
E · Potential for more than minimal harm
2023-08-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-11
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 2023-09-01
E · Potential for more than minimal harm
2023-08-11
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 2023-09-01
E · Potential for more than minimal harm
2023-08-11
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 2023-09-01
E · Potential for more than minimal harm
2022-04-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-10
C · Minimal harm
2022-04-28
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-06-10
Penalties and ownership
What sits behind the stars
Ownership
Mainstreeidence Developments LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
James, David
Contracted Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mcclain, Christopher
Operational/Managerial Control · Individual
Mcclain, Christopher
W-2 Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Neighborhoods Rehabilitation And Skilled Nursing B
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2-star overall rating with 2-star inspections with $68,105 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Villa At Blue Ridge, The
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1-star overall rating with 2-star inspections with abuse icon flag with 22 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Bluffs, The
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2-star overall rating with 2-star inspections with $37,621 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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