Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

BLUE SPRINGS WELLNESS & REHABILITATION

BLUE SPRINGS, MO · 120 certified beds · Last Life Safety survey March 28, 2025

CMS Certification Number 265595 · first certified December 1994

Ownership

Operated by OPCO SKILLED MANAGEMENT · For profit - Limited Liability company

  • New ownershipOwnership changed December 2, 2024 (change of ownership)from SHANGRI LA HCO, LLC
39
Citations on file
Rolling three-year window
6
Life Safety surveys
In the same window
11
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file

Position within MO

39 citations — more than 92% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 6.8. With 6 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: May 2026 to December 2026. This facility’s last Life Safety survey was March 2025. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

10 of the 39 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

15 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 39 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  • F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
  • F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  • F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

How that compares

Citations on file over three years

Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.

This facility39MO median18National median11
Citations on file over three years, compared
MeasureCitations
This facility39
Median facility in MO18
Median facility nationally11

Survey history

Citations at each Life Safety survey
202022-04112023-0712023-0812024-1012024-1252025-03
Citations at each Life Safety survey
Survey dateCitations
April 7, 202220
July 21, 202311
August 24, 20231
October 17, 20241
December 2, 20241
March 28, 20255

Most-cited tags

Most-cited tags at this facility
E-00153K-03742K-03532E-00252E-00202K-03622K-03722K-03632
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0015Address subsistence needs for staff and patients.32023-08-24
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.22023-07-21
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-12-02
E-0025Create arrangements with other facilities to receive patients.22023-07-21
E-0020Establish policies and procedures including evacuation.22023-07-21
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.22023-07-21
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22023-07-21
K-0363Install corridor and hallway doors that block smoke.22023-07-21

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 16
  • Emergency Preparedness Deficiencies 10
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Miscellaneous Deficiencies 4
  • Other 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies16
Emergency Preparedness Deficiencies10
Gas, Vacuum, and Electrical Systems Deficiencies5
Miscellaneous Deficiencies4
Egress Deficiencies3
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 28, 2025 — 5 citations

Citations issued on March 28, 2025
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (May 12, 2025)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (May 12, 2025)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (May 12, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 12, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 12, 2025)

December 2, 2024 — 1 citation

Citations issued on December 2, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (January 15, 2025)

October 17, 2024 — 1 citation

Citations issued on October 17, 2024
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 23, 2024)

August 24, 2023 — 1 citation

Citations issued on August 24, 2023
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (September 20, 2023)

July 21, 2023 — 11 citations

Citations issued on July 21, 2023
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (September 1, 2023)
E-0020Establish policies and procedures including evacuation.Deficient, Provider has date of correction (September 1, 2023)
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (September 1, 2023)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (September 1, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (September 1, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 1, 2023)
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.Deficient, Provider has date of correction (September 1, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 1, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (September 1, 2023)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (September 1, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 1, 2023)

April 7, 2022 — 20 citations

Citations issued on April 7, 2022
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (May 11, 2022)
E-0020Establish policies and procedures including evacuation.Deficient, Provider has date of correction (May 11, 2022)
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (May 11, 2022)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (May 11, 2022)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (May 11, 2022)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (May 11, 2022)
K-0300Meet other general requirements that are deficient.Deficient, Provider has date of correction (May 11, 2022)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (May 11, 2022)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 11, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 11, 2022)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (May 11, 2022)
K-0362Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.Deficient, Provider has date of correction (May 11, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 11, 2022)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (May 11, 2022)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (May 11, 2022)
K-0500Meet other general requirements that are deficient.Deficient, Provider has date of correction (May 11, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 11, 2022)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (May 11, 2022)
K-0919Meet requirements for the use of electrical equipment.Deficient, Provider has date of correction (May 11, 2022)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (May 11, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.