8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Hollister, MO
3-star overall rating with 3-star inspections with $3,250 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
11103 Historic Hwy 165, Hollister, MO
(417) 334-4105
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
130
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1990-02-02
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
RN hours / resident day
0.26
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
1.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.72
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.88
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.49
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Program rank
6,879
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.04
Performance 20.49% · Measure score 2.04 · Achievement 2.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.38
Performance 6.53% · Measure score 4.38 · Achievement 4.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.83
Baseline 35.09% · Performance 43.94% · Measure score 4.83 · Achievement 4.83 · Improvement 0
Adjusted total nurse staffing
1.34
Baseline 3.01 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 1.10
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 5.87% |
| Discharge to community | 54.69% |
50.57%
4.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 47.73% · Lower 95% interval 39.6% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 16.67% |
53.69%
37 pts worse
|
Numerator 4 · Denominator 24 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 12 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.93% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 130 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 10 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 2 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · 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 | 93.6% |
84.8%
8.8 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 100.0% · Q3 88.8% · Q4 89.5% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
90.9%
4.8 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
4.1%
0.3 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.4% · Q3 2.2% · Q4 4.7% · 4Q avg 3.8% · 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 1.2% · Q2 0.0% · Q3 1.2% · Q4 2.4% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.5%
About the same
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.3% · Q3 10.2% · Q4 0.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.0% |
25.3%
23.7 pts worse
|
19.6%
29.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 46.0% · Q3 53.3% · Q4 55.2% · 4Q avg 49.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.5% |
25.0%
6.5 pts worse
|
16.7%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 33.3% · Q3 32.0% · Q4 34.1% · 4Q avg 31.5% · 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 | 24.2% |
20.3%
3.9 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 20.7% · Q3 22.9% · Q4 21.3% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
19.8%
5.7 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 16.1% · Q3 40.7% · Q4 29.8% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.4%
0.7 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.9% · Q4 0.8% · 4Q avg 0.7% · 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 3.8% · Q2 2.3% · Q3 4.5% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
18.1%
7.1 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 16.3% · Q3 30.2% · Q4 29.7% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.0%
1.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 4.7% · Q4 2.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.8% |
66.4%
8.4 pts better
|
81.7%
6.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 92.3% · Q3 97.9% · Q4 41.9% · 4Q avg 74.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
13.4%
0.7 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 14.3% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.1% |
2.2%
3.9 pts worse
|
1.6%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.9% · Q3 9.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.0% |
63.5%
8.5 pts better
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
25.3%
1.6 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 28.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (3 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-08
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-12-08
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-08
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 2024-12-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-08
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-12-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-04
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-04
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-04
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-04
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-04
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-04
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-05-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-26
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-01-26
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-04
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-08-15
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-15
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-08
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-08
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-24
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-03-12
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-04
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-04
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 2023-05-04
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-04
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 2023-05-04
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-04
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-04
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-04
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-04
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 2023-05-04
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 2023-05-04
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-04
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-05-04
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 2023-05-04
Health
Post nurse staffing information every day.
Corrected 2023-05-04
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-04
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-01-26
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 2020-01-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-01-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-01-26
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-01-26
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-01-26
Penalties and ownership
Fine · fine $3,250
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Nearby options
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Berryville, AR
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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