Cycle 1
Health 2025-08-01 · Fire 2025-08-01
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Concordia, MO
Lutheran Nursing Home
4-star overall rating with 4-star inspections with $41,886 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
202 South West Street, Concordia, MO
(660) 463-2267
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Shafiq Malik
Operator or chain grouping
Approved since
2003-10-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 4 health / 2 staffing / 2 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
0.35
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,642
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.94
Baseline 17.42% · Performance 19.61% · Measure score 3.94 · Achievement 3.94 · Improvement 0
Healthcare-associated infections
4.09
Baseline 7.12% · Performance 6.61% · Measure score 4.09 · Achievement 4.09 · Improvement 1.89
Total nurse turnover
0
Baseline 42.22% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.15
Baseline 6.80 hours · Performance 4.83 hours · Measure score 6.15 · Achievement 6.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.57% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 20.34% · Lower 95% interval 9.01% |
| Discharge to community | 44.9% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 36.17% · Lower 95% interval 31.83% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 30 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 9 · Denominator 27 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 6 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 19.71% |
42%
22.3 pts worse
|
Numerator 27 · Denominator 137 |
| Discharge function score | 22.22% |
56.45%
34.2 pts worse
|
Numerator 6 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.33% |
25.2%
16.9 pts worse
|
Numerator 2 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · 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 | 96.8% |
90.9%
5.9 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.5% |
4.1%
3.4 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.1% · Q3 9.5% · Q4 13.4% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.5% |
14.7%
0.2 pts better
|
11.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 16.1% · Q3 16.9% · Q4 15.3% · 4Q avg 14.5% |
| Percentage of long-stay residents who lose too much weight | 13.1% |
5.5%
7.6 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 4.4% · Q3 16.7% · Q4 21.8% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.9% |
25.3%
7.6 pts worse
|
19.6%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 33.3% · Q3 32.1% · Q4 33.3% · 4Q avg 32.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.9% |
25.0%
1.9 pts worse
|
16.7%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 34.5% · Q3 28.6% · Q4 21.3% · 4Q avg 26.9% · 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 | 9.0% |
20.3%
11.3 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 3.0% · Q3 4.5% · Q4 4.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
19.8%
5.7 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 10.6% · Q3 11.3% · Q4 3.6% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.4%
0.5 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.6%
0.1 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.6% · Q3 0.0% · Q4 1.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.6% |
18.1%
2.5 pts better
|
19.8%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 18.1% · Q3 14.4% · Q4 14.3% · 4Q avg 15.6% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.0%
1.5 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.9% · Q3 3.9% · Q4 4.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
66.4%
32.7 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
13.4%
4.1 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.8% · Expected 11.8% · 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 · Q1 9.1% · Q2 12.5% · Q3 0.0% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
63.5%
24.8 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
25.3%
10.6 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 13.7% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-04-13 · Fire 2022-04-13
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
12 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-08-01
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 2025-09-15
F · Potential for more than minimal harm
2025-08-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-15
F · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
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 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-14
F · Potential for more than minimal harm
2022-04-13
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
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 2022-05-28
F · Potential for more than minimal harm
2022-04-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
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 2022-05-28
F · Potential for more than minimal harm
2022-04-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-28
E · Potential for more than minimal harm
2022-04-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-28
E · Potential for more than minimal harm
2022-04-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-05-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-01
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-09-15
D · Potential for more than minimal harm
2024-07-08
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 2024-06-25
E · Potential for more than minimal harm
2024-05-06
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 2024-06-04
E · Potential for more than minimal harm
2023-09-28
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 2023-11-14
D · Potential for more than minimal harm
2023-09-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
F · Potential for more than minimal harm
2022-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-28
F · Potential for more than minimal harm
2022-04-13
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-05-28
E · Potential for more than minimal harm
2022-04-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-05-28
E · Potential for more than minimal harm
2022-04-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
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 2022-05-28
D · Potential for more than minimal harm
2022-04-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-05-28
D · Potential for more than minimal harm
2022-04-13
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-28
Penalties and ownership
What sits behind the stars
$41,886
2023-09-28
Fine
Fine · fine $41,886
Fine
Ownership
Farrell, Kristine
Operational/Managerial Control · Individual
Habibullah, Ayaaz
Operational/Managerial Control · Individual
Malik, Omer
Operational/Managerial Control · Individual
Malik, Shafiq
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Meyer Care Center
Higginsville, MO
2-star overall rating with 2-star inspections with 22 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Apple Ridge Care Center
Waverly, MO
1-star overall rating with 2-star inspections with abuse icon flag with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Country Club Rehab And Healthcare Center
Warrensburg, MO
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out