Cycle 1
Health 2025-07-24 · Fire 2025-07-24
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Westphalia, MO
Stonebridge Westphalia
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1899 Highway 63, Westphalia, MO
(573) 455-2280
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonebridge Senior Living
Operator or chain grouping
Approved since
2004-01-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 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
0.62
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.31
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
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,688
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.56
Performance 18.86% · Measure score 5.56 · Achievement 5.56 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7.04
Performance 5.73% · Measure score 7.04 · Achievement 7.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 58.00% · Performance 65.57% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.99
Baseline 3.47 hours · Performance 3.93 hours · Measure score 2.99 · Achievement 2.99 · Improvement 1.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 5.96% |
| Discharge to community | 38.26% |
50.57%
12.3 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 31.82% · Lower 95% interval 28.74% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 20 · Denominator 32 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 16 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 12.2% |
2.29%
9.9 pts worse
|
Numerator 5 · Denominator 41 · Adjusted rate 13.79% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 0% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 3.45% |
42%
38.5 pts worse
|
Numerator 5 · Denominator 145 |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 17 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
84.8%
4.5 pts better
|
93.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 88.0% · Q3 84.0% · Q4 98.0% · 4Q avg 89.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.9%
9.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.7% |
4.1%
6.6 pts worse
|
3.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 14.0% · Q3 10.0% · Q4 10.2% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
14.7%
13.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 13.6% |
5.5%
8.1 pts worse
|
5.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 20.0% · Q3 4.5% · Q4 5.3% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
25.3%
13.4 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 7.9% · Q3 11.1% · Q4 17.5% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
25.0%
16 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 12.9% · Q3 5.7% · Q4 11.4% · 4Q avg 9.0% · 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 · Q2 15.7% · Q3 42.3% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.3% |
19.8%
12.5 pts worse
|
14.9%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 35.9% · Q3 32.6% · Q4 26.3% · 4Q avg 32.3% · 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 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
2.6%
4.3 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 8.7% · Q3 2.0% · Q4 4.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
18.1%
12.8 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 23.7% · Q3 40.0% · Q4 26.4% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.0%
2.3 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.3% · Q3 9.2% · Q4 4.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.5% |
66.4%
1.1 pts better
|
81.7%
14.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 59.3% · Q3 62.5% · Q4 73.5% · 4Q avg 67.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
13.4%
0.5 pts better
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 10.7% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.2%
0.7 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.2% |
63.5%
8.3 pts worse
|
79.7%
24.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
25.3%
7.5 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 14.3% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
7 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-09-09
F · Potential for more than minimal harm
2025-07-24
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-09-09
F · Potential for more than minimal harm
2025-07-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-09-06
F · Potential for more than minimal harm
2025-07-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-31
F · Potential for more than minimal harm
2025-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-09
D · Potential for more than minimal harm
2024-11-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-05-09
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-20
F · Potential for more than minimal harm
2022-12-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-02
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 2022-12-15
F · Potential for more than minimal harm
2022-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-05
F · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-10
F · Potential for more than minimal harm
2022-12-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-12-19
F · Potential for more than minimal harm
2022-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-07-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-07-24
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 2025-09-09
E · Potential for more than minimal harm
2025-07-24
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 2025-09-09
D · Potential for more than minimal harm
2025-07-24
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-09
E · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-05-09
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 2024-06-20
F · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-05-09
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-20
C · Minimal harm
2024-05-09
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 2024-06-20
G · Actual harm
2023-10-12
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 2023-11-08
F · Potential for more than minimal harm
2022-12-02
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 2023-01-06
F · Potential for more than minimal harm
2022-12-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-01-03
E · Potential for more than minimal harm
2022-12-02
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 2023-01-06
E · Potential for more than minimal harm
2022-12-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-06
C · Minimal harm
2022-12-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-06
C · Minimal harm
2022-12-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-01-06
Penalties and ownership
What sits behind the stars
Ownership
Lierman, Mark
5% Or Greater Direct Ownership Interest · Individual
Berhorst, Tracy
Operational/Managerial Control · Individual
Bridge Rehabilitation Inc
Operational/Managerial Control · Organization
Busey Corporation
Operational/Managerial Control · Organization
Ciegel, Steven
Operational/Managerial Control · Individual
Doerhoff, Eric
Operational/Managerial Control · Individual
Dudenhoeffer, Michael
Operational/Managerial Control · Individual
Eldercare Management Services Inc
Operational/Managerial Control · Organization
Knight, Kara
Operational/Managerial Control · Individual
Lierman, Mark
Operational/Managerial Control · Individual
Lierman, Mark
Corporate Officer · Individual
Miller, Beth
Corporate Officer · Individual
Thayer, Jeanne
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Stonebridge Adams Street
Jefferson City, MO
2-star overall rating with 3-star inspections with $38,656 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Capitol River Wellness & Rehabilitation
Jefferson City, MO
2-star overall rating with 2-star inspections with $14,446 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Stonebridge Villa Marie
Jefferson City, MO
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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