F
39/100BLUE SPRINGS WELLNESS & REHABILITATION Inspection Report, Violations & Safety Grade (BLUE SPRINGS, Missouri)
930 NE DUNCAN ROAD, BLUE SPRINGS, Missouri 64014
Phone: 8162296677
CMS Overall:1/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
106
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Jackson
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes
CMS Star Ratings
Overall1/5
Health2/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Missouri Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.24 | 0.46 | -0.22 |
| Total Nurse Hours per Resident per Day | 2.88 | 3.40 | -0.52 |
| CMS Staffing Rating | 1/5 | 2.2/5 | - |
| Nursing Staff Turnover | 64.5% | 56.9% | - |
Health Citation History
66 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-16 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-07-16 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-11-18 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2025-11-18 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-03-28 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2025-03-28 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2025-03-28 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-03-28 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2025-03-28 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-03-28 | Quality of Life and Care Deficiencies | Provide care or services that was trauma informed and/or culturally competent. | D – Moderate Harm Potential |
| 2025-03-28 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D – Moderate Harm Potential |
| 2025-03-28 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-03-28 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2025-03-28 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-03-28 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2025-03-28 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-12-02 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-10-03 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-04-22 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2023-07-21 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-07-21 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | F – Moderate Harm Potential |
| 2023-07-21 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F – Moderate Harm Potential |
| 2023-07-21 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-07-21 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2023-07-21 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2023-07-21 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2023-07-21 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-07-21 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2023-07-21 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-07-21 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2023-07-21 | Environmental Deficiencies | Have enough outside ventilation via a window or mechanical ventilation, or both. | E – Moderate Harm Potential |
| 2023-07-21 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E – Moderate Harm Potential |
| 2023-07-21 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2023-07-21 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2023-07-21 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-07-21 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D – Moderate Harm Potential |
| 2023-07-21 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-07-21 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-07-21 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-07-21 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2023-07-21 | Nutrition and Dietary Deficiencies | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | D – Moderate Harm Potential |
| 2023-07-21 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2022-04-07 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2022-04-07 | Resident Rights Deficiencies | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Rights Deficiencies | Assure the security of all personal funds of residents deposited with the facility. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | E – Moderate Harm Potential |
| 2022-04-07 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
Showing 50 of 66 citations.
Fire Safety Citation History
38 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-03-28 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2025-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | F – Moderate Harm Potential |
| 2025-03-28 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
| 2025-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2024-12-02 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-10-17 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2023-07-21 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2023-07-21 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | F – Moderate Harm Potential |
| 2023-07-21 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | F – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-07-21 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-07-21 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | E – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-07-21 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2022-04-07 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2022-04-07 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2022-04-07 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | F – Moderate Harm Potential |
| 2022-04-07 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2022-04-07 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2022-04-07 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2022-04-07 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2022-04-07 | Egress Deficiencies | Meet other general requirements that are deficient. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2022-04-07 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2022-04-07 | Services Deficiencies | Meet other general requirements that are deficient. | E – Moderate Harm Potential |
| 2022-04-07 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | E – Moderate Harm Potential |
| 2022-04-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | E – Moderate Harm Potential |
| 2022-04-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
Total Penalties & Fines
$96,959
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-09-27 | Fine | $96,959 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the BLUE SPRINGS area at no cost.
Find Safe, Vetted Facilities Near BLUE SPRINGS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.