Cycle 1
Health 2024-07-23 · Fire 2024-07-23
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Nixa, MO
Nixa Nursing & Rehab
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1104 North Main Street, Nixa, MO
(417) 725-1777
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1988-04-08
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
0.25
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.85
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
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,392
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.59% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 9.48% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 56.14% · Performance 64.63% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.32
Baseline 3.41 hours · Performance 3.74 hours · Measure score 2.32 · Achievement 2.32 · Improvement 0.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.77% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 18.29% · Lower 95% interval 8.65% |
| Discharge to community | 55.32% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 52.05% · Lower 95% interval 42.17% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.74% |
95.27%
4.5 pts worse
|
Numerator 49 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 34.21% |
53.69%
19.5 pts worse
|
Numerator 13 · Denominator 38 |
| Discharge mobility score | 42.11% |
50.94%
8.8 pts worse
|
Numerator 16 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 54 · Adjusted rate 2.07% |
| Healthcare-associated infections requiring hospitalization | 9.48% |
7.12%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 4.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 50.45% |
42%
8.5 pts better
|
Numerator 56 · Denominator 111 |
| Discharge function score | 44.74% |
56.45%
11.7 pts worse
|
Numerator 17 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 76% |
96.28%
20.3 pts worse
|
Numerator 19 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 3 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.0 |
2.1
1.9 pts worse
|
1.9
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
84.8%
8.8 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 94.4% · Q3 91.3% · Q4 89.9% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
90.9%
5.2 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
4.1%
1.9 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.6% · Q3 10.1% · Q4 5.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
14.7%
13.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.0% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.5%
3.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.0% · Q3 1.7% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
25.3%
2.9 pts better
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 23.3% · Q3 16.9% · Q4 21.4% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
25.0%
10.2 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 15.4% · Q3 13.5% · Q4 16.3% · 4Q avg 14.8% · 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 | 16.8% |
20.3%
3.5 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 21.5% · Q3 5.8% · Q4 17.0% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
19.8%
0.6 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 18.6% · Q3 25.4% · Q4 5.5% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.4%
0.8 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.6% · Q3 4.4% · Q4 7.4% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
18.1%
1.3 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.4% · Q3 18.8% · Q4 20.2% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.0%
1.7 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.4% · Q3 6.1% · Q4 8.8% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.9% |
66.4%
14.5 pts better
|
81.7%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 86.2% · Q3 86.4% · Q4 72.1% · 4Q avg 80.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.4% |
13.4%
12 pts worse
|
12.0%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 24.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.2%
0.3 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 2.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
63.5%
21.3 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.3%
1.2 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 26.8% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-16 · Fire 2022-09-16
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-09-26 · Fire 2019-09-26
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-23
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-07-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-03
E · Potential for more than minimal harm
2024-07-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-03
F · Potential for more than minimal harm
2022-09-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-21
E · Potential for more than minimal harm
2022-09-16
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 2022-09-19
E · Potential for more than minimal harm
2022-09-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-09-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-09-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-09-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-11
F · Potential for more than minimal harm
2019-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-31
E · Potential for more than minimal harm
2019-09-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-23
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 2024-09-03
D · Potential for more than minimal harm
2024-07-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-07-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-03
E · Potential for more than minimal harm
2022-09-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-09-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-08
C · Minimal harm
2022-09-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-08
D · Potential for more than minimal harm
2019-09-26
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 2019-10-31
D · Potential for more than minimal harm
2019-09-26
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-31
Penalties and ownership
What sits behind the stars
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Lincoln, James
W-2 Managing Employee · Individual
Ltc Management Services LLC
Operational/Managerial Control · Organization
Nearby options
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#3
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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