Cycle 1
Health 2025-01-03 · Fire 2025-01-03
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
El Dorado Springs, MO
Community Springs Healthcare Facility
3-star overall rating with 4-star inspections with 7 recent health deficiencies
400 East Hospital Road, El Dorado Springs, MO
(417) 876-2531
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Citizens Memorial Health Care
Operator or chain grouping
Approved since
1991-02-01
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
0.40
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.99
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.31
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
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,096
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.11
Baseline 41.51% · Performance 59.16% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Adjusted total nurse staffing
0.57
Baseline 3.63 hours · Performance 3.24 hours · Measure score 0.57 · Achievement 0.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 7.58% |
| Discharge to community | 38.16% |
50.57%
12.4 pts worse
|
Worse than the National Rate · Eligible stays 35 · Observed rate 28.57% · Lower 95% interval 28.09% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 26.92% |
53.69%
26.8 pts worse
|
Numerator 7 · Denominator 26 |
| Discharge mobility score | 23.08% |
50.94%
27.9 pts worse
|
Numerator 6 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 2 · Denominator 32 · Adjusted rate 5.77% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7% |
8.2%
1.2 pts worse
|
Numerator 7 · Denominator 100 |
| Staff flu vaccination coverage | 85.57% |
42%
43.6 pts better
|
Numerator 83 · Denominator 97 |
| Discharge function score | 26.92% |
56.45%
29.5 pts worse
|
Numerator 7 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.43% |
25.2%
5.2 pts better
|
Numerator 7 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.9 |
2.3
2.6 pts worse
|
1.8
3.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.9 · Observed 4.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
84.8%
14.1 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 98.5% · Q4 98.5% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
90.9%
7.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
4.1%
1.9 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.5% · Q3 0.0% · Q4 2.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
14.7%
7.1 pts better
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 3.3% · Q3 6.5% · Q4 11.1% · 4Q avg 7.6% |
| 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 1.7% · Q2 5.2% · Q3 5.0% · Q4 3.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
25.3%
0.8 pts better
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 20.0% · Q3 30.6% · Q4 27.4% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
25.0%
2.3 pts better
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 24.0% · Q3 21.2% · Q4 23.5% · 4Q avg 22.7% · 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 | 21.2% |
20.3%
0.9 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 23.5% · Q3 7.5% · Q4 23.6% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
19.8%
0.9 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 27.1% · Q3 18.0% · Q4 21.3% · 4Q avg 20.7% · 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 · 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 | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 6.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
18.1%
3.4 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 10.7% · Q3 22.9% · Q4 9.7% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.0%
3.3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
66.4%
32.9 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
13.4%
3.5 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
2.2%
4 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
63.5%
36.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
25.3%
1.8 pts better
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 23.3% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-30 · Fire 2023-06-30
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2020-01-10 · Fire 2020-01-10
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-03
E · Potential for more than minimal harm
2023-06-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-03
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 2025-02-17
E · Potential for more than minimal harm
2025-01-03
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 2025-02-17
D · Potential for more than minimal harm
2025-01-03
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 2025-02-17
D · Potential for more than minimal harm
2025-01-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-17
F · Potential for more than minimal harm
2023-06-30
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-06-30
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 2023-08-10
D · Potential for more than minimal harm
2023-06-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-06-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-08-10
E · Potential for more than minimal harm
2020-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-28
Penalties and ownership
What sits behind the stars
Ownership
Ashworth, James
Corporate Director · Individual
Babb, Donald
Corporate Director · Individual
Banner, Katrina
Corporate Officer · Individual
Calhoun, Michael
Corporate Officer · Individual
Calhoun, Michael
W-2 Managing Employee · Individual
Dawson, Eran
Corporate Officer · Individual
Derrickson, Beverly
Corporate Director · Individual
Derrickson, Beverly
Corporate Officer · Individual
Derrickson, Beverly
W-2 Managing Employee · Individual
Finnell, Heather
W-2 Managing Employee · Individual
Fulbright, Gary
Corporate Officer · Individual
Hancock, Janieca
Corporate Director · Individual
Hancock, Janieca
Corporate Officer · Individual
Kallenbach, John
Corporate Director · Individual
Kallenbach, John
Corporate Officer · Individual
Mcbratney, Christopher
W-2 Managing Employee · Individual
Meents, Dana
Corporate Director · Individual
Meyer, Renee
Corporate Officer · Individual
Meyer, Renee
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lake Stockton Healthcare Facility
Stockton, MO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Nathan Richard Health Care Center
Nevada, MO
1-star overall rating with 2-star inspections with $38,532 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Moore Few Care Center
Nevada, MO
3-star overall rating with 3-star inspections with $13,662 in total fines with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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