Cycle 1
Health 2024-03-21 · Fire 2024-03-21
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Branson, MO
Shepherd Of The Hills Living Center
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
996 State Highway 248, Branson, MO
(417) 334-6431
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1989-08-24
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
0.20
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
2.23
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.92
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,457
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.17
Baseline 19.30% · Performance 19.03% · Measure score 5.17 · Achievement 5.17 · Improvement 0.68
Healthcare-associated infections
0
Baseline 5.53% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.06% · Performance 62.34% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.52
Baseline 3.32 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 0.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.77% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 4.49% · Lower 95% interval 5.36% |
| Discharge to community | 59.18% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 51.58% · Lower 95% interval 48.66% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 66 · Denominator 68 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 68 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 24 · Denominator 40 |
| Discharge mobility score | 52.5% |
50.94%
1.6 pts better
|
Numerator 21 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 68 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 12.07% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 10.53% |
42%
31.5 pts worse
|
Numerator 10 · Denominator 95 |
| Discharge function score | 72.5% |
56.45%
16 pts better
|
Numerator 29 · Denominator 40 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | 81.58% |
96.28%
14.7 pts worse
|
Numerator 31 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 5.26% |
25.2%
19.9 pts worse
|
Numerator 2 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.3
1.9 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 37.0% |
84.8%
47.8 pts worse
|
93.4%
56.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.1% · Q2 22.8% · Q3 30.2% · Q4 40.0% · 4Q avg 37.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.3% |
90.9%
22.6 pts worse
|
95.5%
27.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
4.1%
0.6 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.5% · Q3 4.8% · Q4 4.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
14.7%
13.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 2.1% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.5%
2.7 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 0.0% · Q3 2.1% · Q4 2.6% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
25.3%
6.8 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 15.9% · Q3 12.5% · Q4 7.9% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
25.0%
12.9 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 8.1% · Q3 7.9% · Q4 18.2% · 4Q avg 12.1% · 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 | 43.1% |
20.3%
22.8 pts worse
|
16.3%
26.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 43.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.3% |
19.8%
7.5 pts worse
|
14.9%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 34.9% · Q3 31.9% · Q4 29.7% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.4%
1.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.4% |
2.6%
5.8 pts worse
|
1.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 12.5% · Q3 4.8% · Q4 8.0% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
18.1%
0.8 pts worse
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 22.3% · Q3 30.0% · Q4 13.6% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.0%
2.1 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 7.1% · Q4 1.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.7% |
66.4%
27.7 pts worse
|
81.7%
43 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 47.0% · Q3 47.6% · Q4 37.9% · 4Q avg 38.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
13.4%
1.4 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.2%
1.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.0% |
63.5%
20.5 pts worse
|
79.7%
36.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
25.3%
4.5 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.9% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-28 · Fire 2022-07-28
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-03 · Fire 2019-09-03
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-21
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 2024-05-06
F · Potential for more than minimal harm
2024-03-21
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 2024-05-06
F · Potential for more than minimal harm
2024-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-06
E · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-11
E · Potential for more than minimal harm
2022-07-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-04
E · Potential for more than minimal harm
2025-07-29
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 2025-08-25
E · Potential for more than minimal harm
2024-03-21
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 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-21
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 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-21
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 2024-05-06
D · Potential for more than minimal harm
2024-03-21
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 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-05-06
G · Actual harm
2023-11-20
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 2023-12-21
D · Potential for more than minimal harm
2023-09-29
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 2023-10-31
F · Potential for more than minimal harm
2022-07-28
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 2022-09-11
E · Potential for more than minimal harm
2022-07-28
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 2022-09-11
E · Potential for more than minimal harm
2022-07-28
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 2022-09-11
E · Potential for more than minimal harm
2022-07-28
F700 · Quality of Life and Care Deficiencies
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 2022-09-11
E · Potential for more than minimal harm
2022-07-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-11
E · Potential for more than minimal harm
2022-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-07-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-11
D · Potential for more than minimal harm
2022-07-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-11
C · Minimal harm
2022-07-28
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 2022-09-11
D · Potential for more than minimal harm
2019-09-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-03
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 2019-10-18
D · Potential for more than minimal harm
2019-09-03
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 2019-10-18
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
Ltc Management Services LLC
Operational/Managerial Control · Organization
Nearby options
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#3
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