Cycle 1
Health 2024-06-20 · Fire 2024-06-20
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lincoln, MO
Lincoln Community Care Center
2-star overall rating with 3-star inspections with $13,667 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
205 Timberline Drive, Lincoln, MO
(660) 547-3322
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-06-01
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
0.43
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,662
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0022
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.75
Baseline 20.02% · Performance 17.84% · Measure score 7.75 · Achievement 7.75 · Improvement 6.79
Healthcare-associated infections
5.83
Baseline 5.92% · Performance 6.09% · Measure score 5.83 · Achievement 5.83 · Improvement 0
Total nurse turnover
3.09
Performance 51.06% · Measure score 3.09 · Achievement 3.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.72
Baseline 3.93 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 5.36% · Lower 95% interval 6.09% |
| Discharge to community | 47.16% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 43.48% · Lower 95% interval 35.18% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 36 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 12 · Denominator 28 |
| Discharge mobility score | 32.14% |
50.94%
18.8 pts worse
|
Numerator 9 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 2 · Denominator 38 · Adjusted rate 5% |
| Healthcare-associated infections requiring hospitalization | 6.09% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 0% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 3 · Denominator 66 |
| Staff flu vaccination coverage | 7.21% |
42%
34.8 pts worse
|
Numerator 8 · Denominator 111 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 13 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| 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 | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.2 · 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 | 97.9% |
90.9%
7 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
4.1%
1.3 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 6.4% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.7%
14.7 pts better
|
11.4%
11.4 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 who lose too much weight | 3.5% |
5.5%
2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 4.5% · Q4 7.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
25.3%
3.4 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 27.3% · Q3 26.7% · Q4 23.3% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
25.0%
2.2 pts better
|
16.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 25.0% · Q3 26.3% · Q4 21.6% · 4Q avg 22.8% · 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 | 16.5% |
20.3%
3.8 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.4% |
19.8%
9.6 pts worse
|
14.9%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 26.2% · Q3 30.2% · Q4 31.7% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.4%
0.2 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 31.5% |
18.1%
13.4 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 32.5% · Q3 41.4% · Q4 24.3% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.0%
0.5 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.2% · Q3 0.0% · Q4 4.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
66.4%
29.9 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 96.2% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
13.4%
1.5 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
2.2%
2.7 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
25.3%
3.8 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 25.0% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-29 · Fire 2023-03-29
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2020-11-20 · Fire 2020-11-20
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-04
F · Potential for more than minimal harm
2024-06-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-04
E · Potential for more than minimal harm
2024-06-20
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 2024-08-04
F · Potential for more than minimal harm
2023-03-29
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
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 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
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 2023-05-12
E · Potential for more than minimal harm
2023-03-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-12
F · Potential for more than minimal harm
2020-11-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-01-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-20
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-08-04
E · Potential for more than minimal harm
2024-06-20
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 2024-08-04
E · Potential for more than minimal harm
2024-06-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-04
E · Potential for more than minimal harm
2024-06-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-04
E · Potential for more than minimal harm
2024-06-20
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-08-04
K · Immediate jeopardy
2023-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-03-29
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 2023-05-12
E · Potential for more than minimal harm
2023-03-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-12
C · Minimal harm
2023-03-29
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-05-12
F · Potential for more than minimal harm
2020-11-20
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-01-04
F · Potential for more than minimal harm
2020-11-20
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 2021-01-04
E · Potential for more than minimal harm
2020-11-20
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-01-04
E · Potential for more than minimal harm
2020-11-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-01-04
E · Potential for more than minimal harm
2020-11-20
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 2021-01-04
Penalties and ownership
What sits behind the stars
$13,667
2023-10-03
Fine
Fine · fine $13,667
Fine
Ownership
Bentch, James
Corporate Director · Individual
Brethower, Rod
Corporate Director · Individual
Cox, Jeanna
Corporate Director · Individual
Kreisel, Richard
Corporate Director · Individual
Lincoln Community Nursing Home
Operational/Managerial Control · Organization
Mckinney, Kristina
W-2 Managing Employee · Individual
Reser, Cynthia
Corporate Director · Individual
Swearngin, Janice
Corporate Director · Individual
Nearby options
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#2
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#3
Windsor Healthcare & Rehab Center
Windsor, MO
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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