Cycle 1
Health 2025-04-10 · Fire 2025-04-10
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Columbia, MO
Lenoir Health Care Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies
3850 Cartwright Lane, Columbia, MO
(573) 876-5800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Evertrue
Operator or chain grouping
Approved since
1996-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 5 overall / 5 health / 5 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
0.79
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
5.31
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
267
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0244
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.96
Baseline 21.12% · Performance 18.20% · Measure score 6.96 · Achievement 6.96 · Improvement 6.63
Healthcare-associated infections
6.27
Baseline 7.19% · Performance 5.96% · Measure score 6.27 · Achievement 6.27 · Improvement 5.1
Total nurse turnover
8.36
Baseline 43.84% · Performance 29.51% · Measure score 8.36 · Achievement 8.36 · Improvement 7.05
Adjusted total nurse staffing
8.36
Baseline 5.15 hours · Performance 5.46 hours · Measure score 8.36 · Achievement 8.36 · Improvement 4.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.25% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 6.33% |
| Discharge to community | 64.93% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 66 · Observed rate 63.64% · Lower 95% interval 53.53% |
| Medicare spending per beneficiary | 0.48 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 100% |
53.69%
46.3 pts better
|
Numerator 31 · Denominator 31 |
| Discharge mobility score | 74.19% |
50.94%
23.2 pts better
|
Numerator 23 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 6.01% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 0% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 89 |
| Staff flu vaccination coverage | 88.79% |
42%
46.8 pts better
|
Numerator 95 · Denominator 107 |
| Discharge function score | 87.1% |
56.45%
30.6 pts better
|
Numerator 27 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
84.8%
11 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 94.9% · Q3 100.0% · Q4 100.0% · 4Q avg 95.8% |
| 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 | 4.8% |
4.1%
0.7 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.6% · Q3 4.5% · Q4 4.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
14.7%
13.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.5%
2.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 12.5% · Q3 6.2% · Q4 9.4% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
25.3%
16.9 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.2% · Q3 12.5% · Q4 9.4% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
25.0%
7.8 pts better
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 19.0% · Q3 18.2% · Q4 19.2% · 4Q avg 17.2% · 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 | 23.8% |
20.3%
3.5 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.1% |
19.8%
7.3 pts worse
|
14.9%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 36.4% · Q3 25.0% · Q4 27.6% · 4Q avg 27.1% · 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 | 3.6% |
2.6%
1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 9.1% · Q4 2.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
18.1%
6.1 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 24.7% · Q3 28.3% · Q4 16.1% · 4Q avg 24.2% |
| 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 1.5% · Q2 4.6% · Q3 4.6% · Q4 4.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
66.4%
24.8 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 88.9% · Q3 94.6% · Q4 91.7% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.4%
13.4 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 9.1% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 93.5% |
63.5%
30 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.4% |
25.3%
7.9 pts better
|
23.9%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 10.8% · Expected 14.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-06 · Fire 2023-02-06
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-08
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-03-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-03-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-22
F · Potential for more than minimal harm
2023-02-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-23
F · Potential for more than minimal harm
2023-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-18
F · Potential for more than minimal harm
2023-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-02-06
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-03-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-10
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 2025-05-07
E · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-07
F · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-08
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 2024-04-22
D · Potential for more than minimal harm
2024-03-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-08
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-04-22
F · Potential for more than minimal harm
2023-02-06
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 2023-03-20
E · Potential for more than minimal harm
2023-02-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-03
E · Potential for more than minimal harm
2023-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-18
E · Potential for more than minimal harm
2023-02-06
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 2023-03-18
E · Potential for more than minimal harm
2023-02-06
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 2023-03-18
C · Minimal harm
2023-02-06
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-23
B · Minimal harm
2023-02-06
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 2023-03-18
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Senior Services
5% Or Greater Direct Ownership Interest · Organization
Anderson, David
Corporate Officer · Individual
Beumer, Brent
Corporate Director · Individual
Brown, Daniel
Corporate Officer · Individual
Christell, Roy
Corporate Director · Individual
Cooper Carcagno, Valerie
Operational/Managerial Control · Individual
Lin, Walter
Operational/Managerial Control · Individual
Lutheran Senior Services
Operational/Managerial Control · Organization
Marles, Adam
Corporate Officer · Individual
Meadows, Megan
Corporate Director · Individual
Mueller, Harry
Corporate Director · Individual
Schaefer, Ronald
Corporate Officer · Individual
Sneed, Chadwick
Corporate Officer · Individual
Sombart, Lisa
Corporate Director · Individual
Sommer, Christopher
Corporate Director · Individual
Tice, Paul
Corporate Officer · Individual
Toon, Norman
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bluffs, The
Columbia, MO
2-star overall rating with 2-star inspections with $37,621 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Neighborhoods Rehabilitation And Skilled Nursing B
Columbia, MO
2-star overall rating with 2-star inspections with $68,105 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Columbia Manor Health & Rehabilitation
Columbia, MO
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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