Hermitage, MO

Hermitage Nursing & Rehab

4-star overall rating with 4-star inspections with $17,492 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

18599 First Street, Hermitage, MO

(417) 745-2111

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

61

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

James & Judy Lincoln

Operator or chain grouping

Approved since

1984-07-02

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.37

Registered nurse staffing

LPN hours / resident day

0.37

Licensed practical nurse staffing

Aide hours / resident day

2.10

Nurse aide staffing

Weekend hours

2.17

Weekend nurse staffing

RN turnover

67%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.6	2.1 1.5 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	0.7	2.3 1.6 pts better	1.8 1.1 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	84.8% 14.8 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.4%	90.9% 7.5 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	4.1% 2.8 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.5%	14.7% 14.2 pts better	11.4% 10.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	5.8%	5.5% 0.3 pts worse	5.4% 0.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.1%	25.3% 5.8 pts worse	19.6% 11.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	33.8%	25.0% 8.8 pts worse	16.7% 17.1 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	7.8%	20.3% 12.5 pts better	16.3% 8.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	6.3%	19.8% 13.5 pts better	14.9% 8.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.7%	1.4% 0.3 pts worse	1.0% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.7%	2.6% 2.1 pts worse	1.7% 3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	5.7%	18.1% 12.4 pts better	19.8% 14.1 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.6%	66.4% 25.2 pts better	81.7% 9.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication	3.7%	2.2% 1.5 pts worse	1.6% 2.1 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.0%	63.5% 32.5 pts better	79.7% 16.3 pts better	Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-02-01 · Fire 2024-02-01

5 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2022-01-13 · Fire 2022-01-13

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2019-05-28 · Fire 2019-05-28

3 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

F · Potential for more than minimal harm 2024-02-01

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-03-12

F · Potential for more than minimal harm 2024-02-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-12

F · Potential for more than minimal harm 2024-02-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-03-12

E · Potential for more than minimal harm 2024-02-01

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-03-12

E · Potential for more than minimal harm 2024-02-01

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-03-12

E · Potential for more than minimal harm 2024-02-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-03-12

F · Potential for more than minimal harm 2022-01-13

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-02-27

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-02-01

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 2024-03-17

E · Potential for more than minimal harm 2024-02-01

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 2024-03-17

E · Potential for more than minimal harm 2024-02-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-17

D · Potential for more than minimal harm 2024-02-01

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-03-17

D · Potential for more than minimal harm 2024-02-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-03-17

G · Actual harm 2023-05-24

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-07-08

E · Potential for more than minimal harm 2023-05-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-07-08

F · Potential for more than minimal harm 2022-01-13

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-02-27

E · Potential for more than minimal harm 2022-01-13

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 2022-02-27

E · Potential for more than minimal harm 2022-01-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-02-27

D · Potential for more than minimal harm 2022-01-13

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-02-27

D · Potential for more than minimal harm 2022-01-13

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-02-27

D · Potential for more than minimal harm 2022-01-13

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-02-27

D · Potential for more than minimal harm 2019-05-28

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2019-07-08

Penalties and ownership