Cycle 1
Health 2025-05-02 · Fire 2025-05-02
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Versailles, MO
Good Shepherd Care Center
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
1101 West Clay Road, Versailles, MO
(573) 378-5411
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
117
Certified beds
Average residents
51
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-01
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
0.56
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.95
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,963
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9949
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.88
Performance 19.17% · Measure score 4.88 · Achievement 4.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.92
Performance 6.36% · Measure score 4.92 · Achievement 4.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.81
Baseline 58.62% · Performance 52.17% · Measure score 2.81 · Achievement 2.81 · Improvement 1.41
Adjusted total nurse staffing
4.16
Baseline 3.94 hours · Performance 4.26 hours · Measure score 4.16 · Achievement 4.16 · Improvement 1.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 9.46% · Lower 95% interval 7.41% |
| Discharge to community | 64.83% |
50.57%
14.3 pts better
|
Better than the National Rate · Eligible stays 49 · Observed rate 71.43% · Lower 95% interval 54.09% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 63.89% |
53.69%
10.2 pts better
|
Numerator 23 · Denominator 36 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 27 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 6.98% |
2.29%
4.7 pts worse
|
Numerator 3 · Denominator 43 · Adjusted rate 7.55% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 14.41% |
42%
27.6 pts worse
|
Numerator 16 · Denominator 111 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 27 · Denominator 36 |
| 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 | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
84.8%
14.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
4.1%
1 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 4.8% · Q4 8.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
14.7%
13.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| 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 · Q1 5.6% · Q2 3.0% · Q3 2.9% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.9% |
25.3%
7.6 pts worse
|
19.6%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.1% · Q3 34.3% · Q4 27.0% · 4Q avg 32.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
25.0%
12.4 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 10.3% · Q3 13.3% · Q4 13.8% · 4Q avg 12.6% · 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 | 21.6% |
20.3%
1.3 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
19.8%
7.6 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.8% · Q3 8.6% · Q4 19.4% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.4%
0.9 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 0.0% · Q3 1.8% · Q4 2.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.4% |
2.6%
3.8 pts worse
|
1.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.2% · Q3 7.1% · Q4 6.4% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
18.1%
4.3 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 24.6% · Q3 26.4% · Q4 17.6% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.0%
1.3 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.7% · Q3 0.0% · Q4 4.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
66.4%
22.1 pts better
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 93.9% · Q3 85.3% · Q4 86.7% · 4Q avg 88.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
13.4%
0.8 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 14.3% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
63.5%
26.8 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
25.3%
8.5 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 17.1% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
5 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
8 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-09
F · Potential for more than minimal harm
2025-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-05-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-05
F · Potential for more than minimal harm
2024-02-16
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
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.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-01
F · Potential for more than minimal harm
2022-11-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-11-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-11-04
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-01
F · Potential for more than minimal harm
2022-11-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-11-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-11-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-02-16
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-02-16
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 2024-04-01
E · Potential for more than minimal harm
2024-02-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-16
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 2024-04-01
C · Minimal harm
2024-02-16
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-04-01
F · Potential for more than minimal harm
2022-11-04
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 2022-12-19
E · Potential for more than minimal harm
2022-11-04
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-11-04
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 2022-12-30
E · Potential for more than minimal harm
2022-11-04
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 2022-11-30
C · Minimal harm
2022-11-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-30
Penalties and ownership
What sits behind the stars
Ownership
Good Shepherd Care Center
Operational/Managerial Control · Organization
Kroupa, Stacey
Operational/Managerial Control · Individual
Livek, Christine
Operational/Managerial Control · Individual
Smith, Lance
Operational/Managerial Control · Individual
Smith, Lance
Corporate Director · Individual
Zordel, April
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Golden Age Living Center
Stover, MO
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Laurie Care Center
Gravois Mills, MO
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Tipton Oak Manor
Tipton, MO
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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