Cycle 1
Health 2024-10-18 · Fire 2024-10-18
4 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Jefferson City, MO
Heisinger Bluffs Healthcare Western Campus
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1306 West Main Street, Jefferson City, MO
(573) 635-0166
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
69
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Green Tree Healthcare Management
Operator or chain grouping
Approved since
2010-12-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.52
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.68
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
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.09
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,077
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.21% · Performance 22.17% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.45
Baseline 5.56% · Performance 7.40% · Measure score 1.45 · Achievement 1.45 · Improvement 0
Total nurse turnover
6.03
Baseline 75.44% · Performance 42.42% · Measure score 6.03 · Achievement 5.2 · Improvement 6.03
Adjusted total nurse staffing
4.86
Baseline 4.51 hours · Performance 4.46 hours · Measure score 4.86 · Achievement 4.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.1% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 317 · Observed rate 11.67% · Lower 95% interval 9.58% |
| Discharge to community | 57.06% |
50.57%
6.5 pts better
|
Better than the National Rate · Eligible stays 313 · Observed rate 56.23% · Lower 95% interval 51.14% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 182 · Denominator 182 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 182 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 108 · Denominator 144 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 108 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 182 · Adjusted rate 1.15% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 6.13% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 21.18% |
42%
20.8 pts worse
|
Numerator 36 · Denominator 170 |
| Discharge function score | 78.47% |
56.45%
22 pts better
|
Numerator 113 · Denominator 144 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 119 · Denominator 119 |
| Resident COVID-19 vaccinations up to date | 17.31% |
25.2%
7.9 pts worse
|
Numerator 18 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.3
1.5 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 2.9 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.0% |
4.1%
4.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 19.5% |
14.7%
4.8 pts worse
|
11.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.8% · Q3 15.2% · Q4 25.7% · 4Q avg 19.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.5%
2.9 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.3%
5 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 18.5% · Q3 24.1% · Q4 14.3% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.6% |
25.0%
2.6 pts worse
|
16.7%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 33.3% · Q3 28.0% · Q4 26.7% · 4Q avg 27.6% · 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 | 6.4% |
20.3%
13.9 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
19.8%
13 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 6.9% · Q4 14.3% · 4Q avg 6.8% · 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 | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
18.1%
12.1 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 41.2% · Q3 31.0% · Q4 28.6% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.0%
2.3 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.4% · Q3 4.4% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
66.4%
33.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
13.4%
1.2 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 11.9% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.2%
1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 3.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
63.5%
35 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
25.3%
3 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 22.5% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
17 health deficiencies
Top issue: Resident Rights (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-01
F · Potential for more than minimal harm
2024-10-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-01
F · Potential for more than minimal harm
2023-07-20
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 2023-08-31
F · Potential for more than minimal harm
2023-07-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
F · Potential for more than minimal harm
2022-04-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-04-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-19
F · Potential for more than minimal harm
2022-04-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-19
E · Potential for more than minimal harm
2022-04-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-19
E · Potential for more than minimal harm
2022-04-21
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 2022-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-06
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-07-17
D · Potential for more than minimal harm
2024-12-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-20
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2025-02-02
E · Potential for more than minimal harm
2024-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-10-18
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 2024-12-04
D · Potential for more than minimal harm
2024-10-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-06-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-02-27
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 2024-04-05
F · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
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 2023-08-31
E · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-20
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-31
C · Minimal harm
2023-07-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-31
C · Minimal harm
2023-07-20
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 2023-08-31
B · Minimal harm
2023-07-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-03-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-14
E · Potential for more than minimal harm
2022-04-21
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 2022-05-19
E · Potential for more than minimal harm
2022-04-21
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 2022-05-19
Penalties and ownership
What sits behind the stars
Ownership
Hb Operations Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
10-26 Nationwide Tr
5% Or Greater Indirect Ownership Interest · Organization
1026 Enterprises Ii, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ads Capital Trust
5% Or Greater Indirect Ownership Interest · Organization
Fischer, Elazar
5% Or Greater Indirect Ownership Interest · Individual
Fischer, Elazar
Corporate Director · Individual
Fischer, Elazar
Corporate Officer · Individual
Mbm 2016 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mcintire, Stacie
W-2 Managing Employee · Individual
Pc8 Capital Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Sj Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sj Healthcare Capital LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Heisinger Bluffs Rehab And Healthcare Center
Jefferson City, MO
4-star overall rating with 4-star inspections with $17,644 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Stonebridge Villa Marie
Jefferson City, MO
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Stonebridge Adams Street
Jefferson City, MO
2-star overall rating with 3-star inspections with $38,656 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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