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

Chain footprint

58 facilities

Chain averages 3 overall / 3 health / 2 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

0.37

Registered nurse staffing · state 0.46 · national 0.68

LPN hours / resident day

0.37

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

2.85

All reported nurse hours · state 3.47 · national 3.89

Licensed hours

0.75

RN + LPN hours · state 1.14 · national 1.54

Weekend hours

2.17

Weekend nurse staffing · state 3.04 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.42

CMS adjusted total nurse staffing hours

Case-mix index

1.14

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 51% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 57% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,567

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9871

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

4.60

Baseline 50.79% · Performance 44.90% · Measure score 4.60 · Achievement 4.60 · Improvement 1.77

Adjusted total nurse staffing

1.89

Baseline 3.86 hours · Performance 3.62 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.54%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 6.58%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.07	1.02 0.1 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	7.04%	8.2% 1.2 pts worse	Numerator 5 · Denominator 71
Staff flu vaccination coverage	15.28%	42% 26.7 pts worse	Numerator 11 · Denominator 72
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · 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	0.6	2.1 1.5 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.3 · Used in QM five-star
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 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star
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 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
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 · 4Q avg 98.4%
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 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star
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 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5%
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 · Q1 4.3% · Q2 10.2% · Q3 4.2% · Q4 4.2% · 4Q avg 5.8%
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 · Q1 33.3% · Q2 32.0% · Q3 29.8% · Q4 29.2% · 4Q avg 31.1%
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 · Q1 36.1% · Q2 30.6% · Q3 35.1% · Q4 33.3% · 4Q avg 33.8% · 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	7.8%	20.3% 12.5 pts better	16.3% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 0.0% · Q3 8.1% · Q4 14.1% · 4Q avg 7.8% · Used in QM five-star
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 · Q1 12.5% · Q2 2.1% · Q3 4.3% · Q4 6.2% · 4Q avg 6.3% · Used in QM five-star
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 · Q1 1.4% · Q2 0.0% · Q3 1.9% · Q4 3.5% · 4Q avg 1.7% · Used in QM five-star
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 · Q1 1.7% · Q2 1.8% · Q3 7.1% · Q4 8.5% · 4Q avg 4.7% · Used in QM five-star
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 · Q1 14.2% · Q2 3.4% · Q3 3.2% · Q4 1.6% · 4Q avg 5.7%
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 5.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 1.7% · Used in QM five-star
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 · Q1 73.9% · Q2 100.0% · Q3 96.0% · Q4 95.7% · 4Q avg 91.6%
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 · 4Q avg 3.7% · Used in QM five-star
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 · 4Q avg 96.0%

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