Cycle 1
Health 2025-01-02 · Fire 2025-01-02
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Gladstone, MO
Linden Woods Village
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2901 Ne 72nd Street, Gladstone, MO
(816) 268-4000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pivotal Health Care
Operator or chain grouping
Approved since
2016-06-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 4 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
1.18
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,409
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.59% · Performance 22.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.05
Baseline 5.23% · Performance 6.33% · Measure score 5.05 · Achievement 5.05 · Improvement 0
Total nurse turnover
1.27
Baseline 52.27% · Performance 58.49% · Measure score 1.27 · Achievement 1.27 · Improvement 0
Adjusted total nurse staffing
5.61
Baseline 4.57 hours · Performance 4.68 hours · Measure score 5.61 · Achievement 5.61 · Improvement 0.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 9.45% · Lower 95% interval 7.18% |
| Discharge to community | 60.46% |
50.57%
9.9 pts better
|
Better than the National Rate · Eligible stays 124 · Observed rate 59.68% · Lower 95% interval 52.72% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 75 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 40.68% |
53.69%
13 pts worse
|
Numerator 24 · Denominator 59 |
| Discharge mobility score | 55.93% |
50.94%
5 pts better
|
Numerator 33 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 78 · Adjusted rate 3.01% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 3.03% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 12.41% |
8.2%
4.2 pts better
|
Numerator 17 · Denominator 137 |
| Staff flu vaccination coverage | 14.93% |
42%
27.1 pts worse
|
Numerator 33 · Denominator 221 |
| Discharge function score | 57.63% |
56.45%
1.2 pts better
|
Numerator 34 · Denominator 59 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 44.74% |
25.2%
19.5 pts better
|
Numerator 17 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 4.0% |
4.1%
0.1 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q3 3.7% · Q4 4.2% · 4Q avg 4.0% · 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 | 2.9% |
5.5%
2.6 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.7% |
25.3%
19.6 pts better
|
19.6%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
25.0%
20.2 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 4.8% · 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 | 21.2% |
20.3%
0.9 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
19.8%
3.6 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 25.0% · 4Q avg 16.2% · 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 · Q3 0.0% · 4Q avg 0.0% · 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 | 33.9% |
18.1%
15.8 pts worse
|
19.8%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 12.3% · 4Q avg 33.9% |
| 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 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
66.4%
23.6 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 92.9% · Q3 91.0% · Q4 91.6% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
13.4%
8.2 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 4.8% · Expected 10.2% · 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 | 95.4% |
63.5%
31.9 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
25.3%
3.3 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 19.0% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
17 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
F · Potential for more than minimal harm
2023-03-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-09
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 2023-04-14
F · Potential for more than minimal harm
2023-03-09
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 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-03
F · Potential for more than minimal harm
2020-01-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-01-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-02
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 2025-01-24
E · Potential for more than minimal harm
2025-01-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-01-24
E · Potential for more than minimal harm
2025-01-02
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 2025-01-24
D · Potential for more than minimal harm
2025-01-02
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 2025-01-24
D · Potential for more than minimal harm
2025-01-02
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 2025-01-24
D · Potential for more than minimal harm
2025-01-02
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-24
E · Potential for more than minimal harm
2023-03-09
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 2023-05-03
D · Potential for more than minimal harm
2023-03-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-03
E · Potential for more than minimal harm
2020-01-09
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 2020-01-31
E · Potential for more than minimal harm
2020-01-09
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 2020-01-31
D · Potential for more than minimal harm
2020-01-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-01-31
D · Potential for more than minimal harm
2020-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-31
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Jordan
Operational/Managerial Control · Individual
Cheng, Christina
Operational/Managerial Control · Individual
Fizer, Amanda
Operational/Managerial Control · Individual
Gulledge, Scott
Operational/Managerial Control · Individual
Gulledge, Travis
Operational/Managerial Control · Individual
Pivotal Health Care LLC
Operational/Managerial Control · Organization
Scenic Development LLC
Operational/Managerial Control · Organization
Wood, Gilbert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Ignite Medical Resort Kansas City, LLC
Kansas City, MO
4-star overall rating with 3-star inspections with $6,368 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Pleasant Valley Manor Care Center
Liberty, MO
4-star overall rating with 4-star inspections with $37,285 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Northland Rehabilitation & Health Care Center
Kansas City, MO
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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