Carthage, MO

St Luke's Nursing And Rehabilitation

3-star overall rating with 4-star inspections with $17,053 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1220 East Fairview, Carthage, MO

(417) 358-9084

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

82

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1997-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.43

Registered nurse staffing · state 0.46 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.21

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.48

All reported nurse hours · state 3.47 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.14 · national 1.54

Weekend hours

3.14

Weekend nurse staffing · state 3.04 · national 3.43

Weekend RN hours

0.39

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

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.64

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 51% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 57% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,790

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

42.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9956

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.83

Baseline 22.64% · Performance 19.09% · Measure score 5.83 · Achievement 5.05 · Improvement 5.83

Healthcare-associated infections

6.67

Baseline 11.00% · Performance 6.69% · Measure score 6.67 · Achievement 3.82 · Improvement 6.67

Total nurse turnover

3.02

Baseline 60.00% · Performance 51.35% · Measure score 3.02 · Achievement 3.02 · Improvement 1.96

Adjusted total nurse staffing

1.55

Baseline 3.19 hours · Performance 3.52 hours · Measure score 1.55 · Achievement 1.55 · Improvement 0.75

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.93%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 110 · Observed rate 10% · Lower 95% interval 7.49%
Discharge to community	49.69%	50.57% 0.9 pts worse	No Different than the National Rate · Eligible stays 92 · Observed rate 43.48% · Lower 95% interval 40.41%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 52 · Denominator 52
Falls with major injury	7.69%	0.77% 6.9 pts worse	Numerator 4 · Denominator 52
Discharge self-care score	34.29%	53.69% 19.4 pts worse	Numerator 12 · Denominator 35
Discharge mobility score	28.57%	50.94% 22.4 pts worse	Numerator 10 · Denominator 35
Pressure ulcers or injuries, new or worsened	1.92%	2.29% 0.4 pts better	Numerator 1 · Denominator 52 · Adjusted rate 1.98%
Healthcare-associated infections requiring hospitalization	6.69%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 4.35% · Lower 95% interval 3.65%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 113
Staff flu vaccination coverage	7.69%	42% 34.3 pts worse	Numerator 11 · Denominator 143
Discharge function score	48.57%	56.45% 7.9 pts worse	Numerator 17 · Denominator 35
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	80.95%	96.28% 15.3 pts worse	Numerator 17 · Denominator 21
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 34

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.7 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.3 0.6 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	77.2%	84.8% 7.6 pts worse	93.4% 16.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 80.3% · Q2 71.2% · Q3 75.8% · Q4 81.2% · 4Q avg 77.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	90.9% 7.7 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	4.1% 0.4 pts better	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 3.2% · Q4 2.9% · 4Q avg 3.7% · 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	3.5%	5.5% 2 pts better	5.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 4.1% · Q4 5.9% · 4Q avg 3.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.0%	25.3% 9.3 pts better	19.6% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 11.8% · Q3 16.0% · Q4 18.9% · 4Q avg 16.0%
Percentage of long-stay residents who received an antipsychotic medication	27.3%	25.0% 2.3 pts worse	16.7% 10.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 26.2% · Q3 23.3% · Q4 26.1% · 4Q avg 27.3% · 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	26.6%	20.3% 6.3 pts worse	16.3% 10.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 21.5% · Q4 31.5% · 4Q avg 26.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.4%	19.8% 5.6 pts worse	14.9% 10.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 21.3% · Q3 14.3% · Q4 34.6% · 4Q avg 25.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	1.4% 0.2 pts better	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.1%	2.6% 0.5 pts worse	1.7% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 4.9% · Q4 4.5% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.7%	18.1% 9.6 pts worse	19.8% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 29.3% · Q3 29.8% · Q4 24.3% · 4Q avg 27.7%
Percentage of long-stay residents with pressure ulcers	4.2%	5.0% 0.8 pts better	5.1% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.2% · Q3 4.0% · Q4 4.8% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	64.3%	66.4% 2.1 pts worse	81.7% 17.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 64.1% · Q3 45.0% · Q4 63.8% · 4Q avg 64.3%
Percentage of short-stay residents who had an outpatient emergency department visit	12.6%	13.4% 0.8 pts better	12.0% 0.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 11.1% · Expected 9.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.2%	2.2% 2 pts worse	1.6% 2.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 10.0% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.1%	63.5% 21.6 pts better	79.7% 5.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.7%	25.3% 8.4 pts worse	23.9% 9.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 28.9% · Expected 20.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-09 · Fire 2025-05-09

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-07-17 · Fire 2023-07-17

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2020-02-11 · Fire 2020-02-11

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-05-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-05-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-05-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-05-09

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-06-20

K · Immediate jeopardy 2023-07-17

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 2023-08-30

F · Potential for more than minimal harm 2023-07-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-30

E · Potential for more than minimal harm 2023-07-17

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-08-30

E · Potential for more than minimal harm 2023-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-30

E · Potential for more than minimal harm 2023-07-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-30

E · Potential for more than minimal harm 2020-02-11

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2020-04-03

E · Potential for more than minimal harm 2020-02-11

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 2020-04-03

E · Potential for more than minimal harm 2020-02-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-04-03

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-09

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-06-20

F · Potential for more than minimal harm 2025-05-09

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-05-09

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2025-06-20

E · Potential for more than minimal harm 2025-05-09

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-05-09

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 2025-06-20

D · Potential for more than minimal harm 2025-05-09

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 2024-11-18

E · Potential for more than minimal harm 2023-07-17

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 2023-08-30

E · Potential for more than minimal harm 2023-07-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-30

D · Potential for more than minimal harm 2023-07-17

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 2023-08-30

D · Potential for more than minimal harm 2023-07-17

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 2023-08-30

D · Potential for more than minimal harm 2023-07-17

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-08-30

D · Potential for more than minimal harm 2023-07-17

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-08-30

D · Potential for more than minimal harm 2023-07-17

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-08-30

D · Potential for more than minimal harm 2023-07-17

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2023-08-30

E · Potential for more than minimal harm 2020-02-11

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2020-04-03

E · Potential for more than minimal harm 2020-02-11

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2020-04-03

D · Potential for more than minimal harm 2020-02-11

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2020-04-03

D · Potential for more than minimal harm 2020-02-11

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 2020-04-03

D · Potential for more than minimal harm 2020-02-11

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2020-04-03

Penalties and ownership

What sits behind the stars

$17,053 2023-07-17

Fine

Fine · fine $17,053

Fine