01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-09 | 9 | 2026-01-09 | 9 |
| Cycle 2 | 2024-02-06 | 9 | 2024-02-06 | 13 |
| Cycle 3 | 2022-07-19 | 7 | 2022-07-19 | 0 |
CMS CCN 2657682026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bishop Spencer Place, Inc, The
4301 Madison Avenue · Kansas City, MO 64111 · Jackson County
Certified beds57CMS provider file
Recent citation rows47current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
47 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-09 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0607Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-03-062026-01-09 · HEALTHF0881Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2026-03-062026-01-09 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0911Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has date of correction · 2026-02-232026-01-09 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2026-02-232024-07-29 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-08-28 · complaint2024-07-29 · HEALTHF0760Severity J · isolated immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-07-25 · complaint2024-02-06 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2024-03-222024-02-06 · HEALTHF0569Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Correction field: Deficient, Provider has date of correction · 2024-03-222024-02-06 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-03-222024-02-06 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-03-2203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-07-29 | Fine | $8,021 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ACHELPHOL, RICHARDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- CALVIN, KARENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- COULTER, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- ELVING, BEVERLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2019
- HAVENHILL, LISAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/19/2020
- HUTCHERSON, ANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- JOHNSON, JANIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/15/2020
- JOHNSTON, NANETTEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- KEYSE, ANDREWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- LAMPO, JANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2022
- MCBRIDE, SYDNEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/11/2025
- MEAUX, AMYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/03/2025
- PURCELL, JASONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- WOOTTON, KRISTENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- HAVENHILL, LISAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/19/2019
- MCBRIDE, SYDNEYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/11/2025
- SAINT LUKES HEALTH SYSTEM INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/16/1996
- ACHELPHOL, RICHARDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.46per resident day
RN hours0.84per resident day
Weekend nurse hours4.41per resident day
Staff turnover40.6%CMS reported field
06 / LOCAL RECORDS
Open the Kansas City ledger →Other published facilities nearby
Armour Oaks Senior Living Community38 beds · CMS overall 2/573 citation rowsBridgewood Health Care Center166 beds · CMS overall 1/5161 citation rowsClara Manor Nursing Home90 beds · CMS overall 1/5127 citation rowsGregory Ridge Health Care Center116 beds · CMS overall 1/5144 citation rowsHighland Rehabilitation & Health Care Center162 beds · CMS overall 3/577 citation rowsHilltop At Blue River, The160 beds · CMS overall 2/585 citation rowsHope Care Center16 beds · CMS overall 5/558 citation rowsIgnite Medical Resort Carondelet Llc162 beds · CMS overall 1/5126 citation rows